Provider Demographics
NPI:1760430698
Name:SHIRLEY Y GODIWALLA M.D,S.C
Entity Type:Organization
Organization Name:SHIRLEY Y GODIWALLA M.D,S.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:Y
Authorized Official - Last Name:GODIWALLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-695-3050
Mailing Address - Street 1:W283N3671 YORKSHIRE TRCE
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3311
Mailing Address - Country:US
Mailing Address - Phone:262-695-3050
Mailing Address - Fax:262-695-3051
Practice Address - Street 1:10625 W NORTH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2315
Practice Address - Country:US
Practice Address - Phone:414-727-1117
Practice Address - Fax:414-727-1118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26973208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31392600Medicaid
340012140OtherRR MEDICARE
WI000081934Medicare PIN
WI000082021Medicare PIN
WI000001351Medicare PIN
WI31392600Medicaid