Basic Information
| Provider Information | |||||||||
| NPI: | 1124294988 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DHOBALE | ||||||||
| FirstName: | SUDHIR | ||||||||
| MiddleName: | D | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 30 E APPLE ST | ||||||||
| Address2: | STE NW 3300 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372088394 | ||||||||
| FaxNumber: | 9372088388 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 E APPLE ST | ||||||||
| Address2: | STE NW 3300 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372088394 | ||||||||
| FaxNumber: | 9372088388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2008 | ||||||||
| LastUpdateDate: | 04/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MT191226 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD439566 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35-097985 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0054712 | 05 | OH | MEDICAID |