Basic Information
| Provider Information | |||||||||
| NPI: | 1407820392 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOSWAMI | ||||||||
| FirstName: | AJANTA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 N TILLOTSON AVE | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473043988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652881928 | ||||||||
| FaxNumber: | 7657410335 | ||||||||
| Practice Location | |||||||||
| Address1: | 3620 W WHITE RIVER BLVD | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473044286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652881928 | ||||||||
| FaxNumber: | 7652882032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 09/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 01050577 | IN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 200237850 | 05 | IN | MEDICAID |