Healthcare Provider Details

I. General information

NPI: 1497073563
Provider Name (Legal Business Name): ELIHU LAKE GODSHALK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 E HOLLISTER ST
CINCINNATI OH
45219-1704
US

IV. Provider business mailing address

3200 VINE ST FL 7 CINCINNATI VA MEDICAL CENTER
CINCINNATI OH
45220-2213
US

V. Phone/Fax

Practice location:
  • Phone: 513-721-1737
  • Fax:
Mailing address:
  • Phone: 513-309-6183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number35.122029
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: