Provider Demographics
NPI:1992829170
Name:GODISHALA, CHAITANYA
Entity Type:Individual
Prefix:
First Name:CHAITANYA
Middle Name:
Last Name:GODISHALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 BRIDGE ST
Mailing Address - Street 2:BULDING E
Mailing Address - City:METUCHEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08840-2294
Mailing Address - Country:US
Mailing Address - Phone:732-516-0090
Mailing Address - Fax:
Practice Address - Street 1:249 BRIDGE ST
Practice Address - Street 2:BLDG E
Practice Address - City:METUCHEN
Practice Address - State:NJ
Practice Address - Zip Code:08840-2294
Practice Address - Country:US
Practice Address - Phone:732-516-0090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01607000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ19928229170Medicaid