1760430698 NPI number — SHIRLEY Y GODIWALLA M.D,S.C

Table of content: (NPI 1760430698)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760430698 NPI number — SHIRLEY Y GODIWALLA M.D,S.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHIRLEY Y GODIWALLA M.D,S.C
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760430698
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
W283N3671 YORKSHIRE TRCE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53072-3311
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-695-3050
Provider Business Mailing Address Fax Number:
262-695-3051

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10625 W NORTH AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
WAUWATOSA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53226-2315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-727-1117
Provider Business Practice Location Address Fax Number:
414-727-1118
Provider Enumeration Date:
05/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GODIWALLA
Authorized Official First Name:
SHIRLEY
Authorized Official Middle Name:
Y
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
262-695-3050

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  26973 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 31392600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 340012140 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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