Provider Demographics
NPI:1861587289
Name:KOUL, NIDHI (MD)
Entity type:Individual
Prefix:
First Name:NIDHI
Middle Name:
Last Name:KOUL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2617 S. ELM PLACE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-7850
Mailing Address - Country:US
Mailing Address - Phone:918-455-6980
Mailing Address - Fax:918-449-9749
Practice Address - Street 1:2617 S. ELM PLACE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-7850
Practice Address - Country:US
Practice Address - Phone:918-455-6980
Practice Address - Fax:918-449-9749
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA224299208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1300172Medicaid
MA486892OtherTUFTS
MA0036582OtherNHP
OK200222490AMedicaid
MAJ29428OtherBC BS OF MA
MAAA40070OtherHARVARD PILGRIM
MA3986470OtherAETNA
RI412987OtherBC BS OF RI
MA000000031938OtherBMC HEALTHNET PLAN
MA89793OtherCMSP
MAJ29428OtherBC BS OF MA
MA3986470OtherAETNA