Provider Demographics
NPI:1215230164
Name:WADIWALA, TINA GODWIN (DO)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:GODWIN
Last Name:WADIWALA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:GODWIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:107 S FAIR OAKS AVE STE 313
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2084
Mailing Address - Country:US
Mailing Address - Phone:626-487-7766
Mailing Address - Fax:
Practice Address - Street 1:107 S FAIR OAKS AVE STE 313
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2084
Practice Address - Country:US
Practice Address - Phone:626-487-7766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-15
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11528207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH121940Medicare PIN