Provider Demographics
NPI:1902822455
Name:GHODASARA, DILIP P (MD)
Entity Type:Individual
Prefix:
First Name:DILIP
Middle Name:P
Last Name:GHODASARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DILIPKUMAR
Other - Middle Name:P
Other - Last Name:GHODASARA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4 SHAMBLIN PL
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-2154
Mailing Address - Country:US
Mailing Address - Phone:304-744-4086
Mailing Address - Fax:304-466-2928
Practice Address - Street 1:217 S 3RD ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1823
Practice Address - Country:US
Practice Address - Phone:859-335-9041
Practice Address - Fax:859-335-9072
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18267207R00000X
OH35.077664207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0078302000Medicaid
WV1036692OtherBWC
OH2060442Medicaid
TN4401035Medicaid
KYP00212624OtherRR-MEDICARE
KY000000384513OtherANTHEM
WV001716933OtherMT. STATE BCBS
KYP00212624OtherRR-MEDICARE
TN4401035Medicaid