Provider Demographics
NPI:1316042567
Name:GODBOLE, SHUBHANGI SUDHIR (MD)
Entity Type:Individual
Prefix:DR
First Name:SHUBHANGI
Middle Name:SUDHIR
Last Name:GODBOLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1814 LEXINGTON DR
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3500
Mailing Address - Country:US
Mailing Address - Phone:714-738-8089
Mailing Address - Fax:714-879-5428
Practice Address - Street 1:501 S IDAHO ST STE 100
Practice Address - Street 2:
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-6047
Practice Address - Country:US
Practice Address - Phone:562-690-0400
Practice Address - Fax:562-690-3182
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41942207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C419420Medicaid
WC41942AMedicare ID - Type Unspecified
CA00C419420Medicaid