Provider Demographics
NPI:1275654667
Name:GODBOLE, SHIRISH R (OTR CHT)
Entity Type:Individual
Prefix:
First Name:SHIRISH
Middle Name:R
Last Name:GODBOLE
Suffix:
Gender:M
Credentials:OTR CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 ROUTE 34
Mailing Address - Street 2:SUITE F PROFESSIONAL BLDG
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857
Mailing Address - Country:US
Mailing Address - Phone:732-727-7333
Mailing Address - Fax:732-727-7333
Practice Address - Street 1:40 ROUTE 34
Practice Address - Street 2:SUITE F PROFESSIONAL BLDG
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857
Practice Address - Country:US
Practice Address - Phone:732-727-7333
Practice Address - Fax:732-727-7333
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTR001614225X00000X
NJ9511000027225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
038176Medicare ID - Type Unspecified