Provider Demographics
NPI:1922051952
Name:GOSWAMY, ICHCHA (MD)
Entity Type:Individual
Prefix:
First Name:ICHCHA
Middle Name:
Last Name:GOSWAMY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 ZECKENDORF BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-2133
Mailing Address - Country:US
Mailing Address - Phone:516-542-6880
Mailing Address - Fax:526-542-5556
Practice Address - Street 1:300 BAY SHORE RD
Practice Address - Street 2:
Practice Address - City:NORTH BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11703-2823
Practice Address - Country:US
Practice Address - Phone:631-586-2700
Practice Address - Fax:631-586-3524
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136782207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00941497Medicaid
NY32F151Medicare ID - Type Unspecified
NYE87279Medicare UPIN