Provider Demographics
NPI:1689752701
Name:GODBOLE, SONIA A (MD)
Entity Type:Individual
Prefix:
First Name:SONIA
Middle Name:A
Last Name:GODBOLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11801 N TATUM BLVD STE 128
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-1620
Mailing Address - Country:US
Mailing Address - Phone:602-795-9980
Mailing Address - Fax:602-795-9984
Practice Address - Street 1:11801 N TATUM BLVD STE 128
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-1620
Practice Address - Country:US
Practice Address - Phone:602-795-9980
Practice Address - Fax:602-795-9984
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ304082084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ716847Medicaid
AZ716847Medicaid
AZ102388Medicare ID - Type Unspecified