Provider Demographics
NPI:1912168857
Name:GOSWAMI, PUJA (MD)
Entity Type:Individual
Prefix:
First Name:PUJA
Middle Name:
Last Name:GOSWAMI
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 1:6622 N 91ST AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85305-2569
Mailing Address - Country:US
Mailing Address - Phone:602-759-6883
Mailing Address - Fax:602-224-3358
Practice Address - Street 1:5750 W THUNDERBIRD RD STE F680
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306
Practice Address - Country:US
Practice Address - Phone:602-843-7171
Practice Address - Fax:602-866-1440
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ54521207RN0300X
CAA126554207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ298466Medicaid