Provider Demographics
NPI:1720148612
Name:GOSWAMI, SANJEEV KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:SANJEEV
Middle Name:KUMAR
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 1:1801 E MARCH LN
Mailing Address - Street 2:STOCKTON
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-6629
Mailing Address - Country:US
Mailing Address - Phone:209-464-6422
Mailing Address - Fax:209-464-0193
Practice Address - Street 1:1801 E MARCH LANE
Practice Address - Street 2:STOCKTON
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6676
Practice Address - Country:US
Practice Address - Phone:209-464-6422
Practice Address - Fax:209-464-0193
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5308207R00000X
CAA88835207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1720148612Medicaid
TX8V4803OtherBCBS
CAGR050180Medicaid
TX8M5418OtherBCBS
CAZZZ28595ZOtherBLUE CROSS/BLUE SHIELD
CAZZZ28595ZOtherBLUE CROSS/BLUE SHIELD
CAZZZ25366ZMedicare PIN
CA1720148612Medicaid