Healthcare Provider Details

I. General information

NPI: 1689752701
Provider Name (Legal Business Name): SONIA A GODBOLE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11801 N TATUM BLVD STE 128
PHOENIX AZ
85028-1620
US

IV. Provider business mailing address

11801 N TATUM BLVD STE 128
PHOENIX AZ
85028-1620
US

V. Phone/Fax

Practice location:
  • Phone: 602-795-9980
  • Fax: 602-795-9984
Mailing address:
  • Phone: 602-795-9980
  • Fax: 602-795-9984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number30408
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: