Healthcare Provider Details

I. General information

NPI: 1710917588
Provider Name (Legal Business Name): GEORGE MATTHEN KOSHY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W COMMERCIAL BLVD SUITE 115
FORT LAUDERDALE FL
33309-3073
US

IV. Provider business mailing address

2000 W COMMERCIAL BLVD SUITE 115
FORT LAUDERDALE FL
33309-3073
US

V. Phone/Fax

Practice location:
  • Phone: 954-839-8080
  • Fax: 954-839-8081
Mailing address:
  • Phone: 954-839-8080
  • Fax: 954-839-8081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME96137
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: