Provider Demographics
NPI:1003996125
Name:GODBOLE, MUKUND (MD)
Entity Type:Individual
Prefix:DR
First Name:MUKUND
Middle Name:
Last Name:GODBOLE
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 1:1000 W HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:IL
Mailing Address - Zip Code:61462-1007
Mailing Address - Country:US
Mailing Address - Phone:309-734-3141
Mailing Address - Fax:
Practice Address - Street 1:1000 W HARLEM AVE
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-1007
Practice Address - Country:US
Practice Address - Phone:309-734-3141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17209208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC03242OtherMEDICARE CAHABA
MSP00269826OtherPALMETTO MEDICARE RAILROA
MS02820846Medicaid
C44750Medicare UPIN
MS02820846Medicaid