Provider Demographics
NPI:1902835135
Name:GOSWAMI, VARDHANA (MD)
Entity Type:Individual
Prefix:DR
First Name:VARDHANA
Middle Name:
Last Name:GOSWAMI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:VARDHANA
Other - Middle Name:
Other - Last Name:KALEPU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5730 EXECUTIVE DR STE 230
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-1762
Mailing Address - Country:US
Mailing Address - Phone:215-443-3850
Mailing Address - Fax:215-443-3963
Practice Address - Street 1:10000 ANNS CHOICE WAY
Practice Address - Street 2:
Practice Address - City:WARMINSTER
Practice Address - State:PA
Practice Address - Zip Code:18974-3527
Practice Address - Country:US
Practice Address - Phone:215-443-3850
Practice Address - Fax:215-443-3963
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD066830L207RG0300X
PAMD066830-L207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0769994000OtherINDEPENDENCE BLUE CROSS
PA7951311OtherAETNA
PA30000892OtherKEYSTONE MERCY
PA0017871400003Medicaid
PA348423OtherHIGHMARK BLUE SHIELD
PA110237110OtherRAILROAD MEDICARE
PA035086QMNMedicare PIN
PA348423OtherHIGHMARK BLUE SHIELD
PA0769994000OtherINDEPENDENCE BLUE CROSS
PA0017871400003Medicaid