Healthcare Provider Details

I. General information

NPI: 1720148612
Provider Name (Legal Business Name): SANJEEV KUMAR GOSWAMI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 09/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 E MARCH LANE STOCKTON
STOCKTON CA
95210-6676
US

IV. Provider business mailing address

1801 E MARCH LN STOCKTON
STOCKTON CA
95210-6629
US

V. Phone/Fax

Practice location:
  • Phone: 209-464-6422
  • Fax: 209-464-0193
Mailing address:
  • Phone: 209-464-6422
  • Fax: 209-464-0193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM5308
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA88835
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: