Provider Demographics
NPI:1073659272
Name:GODBOLE, SHYAMALI V (MD)
Entity Type:Individual
Prefix:DR
First Name:SHYAMALI
Middle Name:V
Last Name:GODBOLE
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:101 E OLNEY AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120-2421
Mailing Address - Country:US
Mailing Address - Phone:215-456-7000
Mailing Address - Fax:215-456-2356
Practice Address - Street 1:5501 OLD YORK RD
Practice Address - Street 2:LEVY 2 WEST
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3018
Practice Address - Country:US
Practice Address - Phone:215-456-6959
Practice Address - Fax:215-456-2356
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2015-08-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD053000L2080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001474726Medicaid
PAF83337Medicare UPIN
PA077409Medicare ID - Type Unspecified