Provider Demographics
NPI:1730165481
Name:KOOLWAL, HARISH
Entity type:Individual
Prefix:
First Name:HARISH
Middle Name:
Last Name:KOOLWAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 W SAM HOUSTON BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-5346
Mailing Address - Country:US
Mailing Address - Phone:956-994-1177
Mailing Address - Fax:956-283-0647
Practice Address - Street 1:214 W SAM HOUSTON BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:PHARR
Practice Address - State:TX
Practice Address - Zip Code:78577-5346
Practice Address - Country:US
Practice Address - Phone:956-994-1177
Practice Address - Fax:956-283-0647
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7771207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127601606Medicaid
TX8454N0OtherBLUE CROSS PIN
TX8454N0OtherBLUE CROSS PIN
TX8454N0Medicare PIN