Healthcare Provider Details

I. General information

NPI: 1598224412
Provider Name (Legal Business Name): VIVEK AJAY KOSHTI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1120 15TH ST
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-0211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number113219
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: