Basic Information
| Provider Information | |||||||||
| NPI: | 1316042567 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GODBOLE | ||||||||
| FirstName: | SHUBHANGI | ||||||||
| MiddleName: | SUDHIR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1814 LEXINGTON DR | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928353500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147388089 | ||||||||
| FaxNumber: | 7148795428 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S IDAHO ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | LA HABRA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906316047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626900400 | ||||||||
| FaxNumber: | 5626903182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 05/02/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | C41942 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00C419420 | 05 | CA | MEDICAID |