Provider Demographics
NPI:1366404139
Name:GOSWAMI, PROMILLA NMN (MD)
Entity type:Individual
Prefix:MRS
First Name:PROMILLA
Middle Name:NMN
Last Name:GOSWAMI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:PROMILLA
Other - Middle Name:U
Other - Last Name:MALLIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:106 SEVEN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-6100
Mailing Address - Country:US
Mailing Address - Phone:910-480-0776
Mailing Address - Fax:
Practice Address - Street 1:2300 RAMSEY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-3856
Practice Address - Country:US
Practice Address - Phone:910-488-2120
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208313207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H02089Medicare UPIN