Provider Demographics
NPI:1124108493
Name:KOSHY, SANTHOSH (MD)
Entity type:Individual
Prefix:DR
First Name:SANTHOSH
Middle Name:
Last Name:KOSHY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 JEFFERSON AVE
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2807
Mailing Address - Country:US
Mailing Address - Phone:901-545-8336
Mailing Address - Fax:
Practice Address - Street 1:1722 SHAFFER ST STE 1
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1633
Practice Address - Country:US
Practice Address - Phone:269-381-3963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2993207RC0000X
TNPENDING207RC0000X
TN43424207RI0011X
MI4301506296207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176385601Medicaid
TX176385601Medicaid
8D9959Medicare ID - Type Unspecified