Provider Demographics
NPI:1508829896
Name:GODSE, RAVINDRA (MD)
Entity Type:Individual
Prefix:
First Name:RAVINDRA
Middle Name:
Last Name:GODSE
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 1:4520 PENN AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224-1314
Mailing Address - Country:US
Mailing Address - Phone:412-681-4211
Mailing Address - Fax:412-681-2315
Practice Address - Street 1:4520 PENN AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-1314
Practice Address - Country:US
Practice Address - Phone:412-681-4211
Practice Address - Fax:412-681-2315
Is Sole Proprietor?:No
Enumeration Date:2006-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD065402L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018768490001Medicaid
PA022872F16Medicare ID - Type Unspecified
PA0018768490001Medicaid