Provider Demographics
NPI:1912184920
Name:THOMAS, BIJU KOSHY (MD)
Entity Type:Individual
Prefix:
First Name:BIJU
Middle Name:KOSHY
Last Name:THOMAS
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 1:6821 PALISADES PARK CT
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-7131
Mailing Address - Country:US
Mailing Address - Phone:239-936-8555
Mailing Address - Fax:239-936-5611
Practice Address - Street 1:6821 PALISADES PARK CT
Practice Address - Street 2:SUITE 1
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-7131
Practice Address - Country:US
Practice Address - Phone:239-936-8555
Practice Address - Fax:239-936-5611
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME122133208600000X
PAMD434294208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014709500Medicaid
FL014709500Medicaid