Provider Demographics
NPI:1467534701
Name:GOSWAMI, NILESH J (MD)
Entity Type:Individual
Prefix:
First Name:NILESH
Middle Name:J
Last Name:GOSWAMI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:979-691-3300
Mailing Address - Fax:
Practice Address - Street 1:50 HILLCREST MEDICAL BLVD STE 102
Practice Address - Street 2:SUITE 303
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712
Practice Address - Country:US
Practice Address - Phone:254-202-0480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT3088207RI0011X
IL036096552207RC0000X
IL036-096552174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL00034820OtherRAILROAD
IL036096552Medicaid
ILL99406Medicare ID - Type Unspecified
IL036096552Medicaid