1902822455 NPI number — DILIP P GHODASARA MD

Table of content: DILIP P GHODASARA MD (NPI 1902822455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902822455 NPI number — DILIP P GHODASARA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GHODASARA
Provider First Name:
DILIP
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GHODASARA
Provider Other First Name:
DILIPKUMAR
Provider Other Middle Name:
P
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1902822455
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 SHAMBLIN PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25314-2154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-744-4086
Provider Business Mailing Address Fax Number:
304-466-2928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
217 S 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40422-1823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-335-9041
Provider Business Practice Location Address Fax Number:
859-335-9072
Provider Enumeration Date:
07/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  18267 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 35.077664 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0078302000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1036692 . This is a "BWC" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 2060442 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4401035 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00212624 . This is a "RR-MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000384513 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 001716933 . This is a "MT. STATE BCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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