Provider Demographics
NPI:1518929611
Name:GODIWALLA, SHIRLEY Y (MD)
Entity type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:Y
Last Name:GODIWALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W283N3671 YORKSHIRE TRCE
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3311
Mailing Address - Country:US
Mailing Address - Phone:262-695-3052
Mailing Address - Fax:
Practice Address - Street 1:W283N3671 YORKSHIRE TRCE
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3311
Practice Address - Country:US
Practice Address - Phone:262-695-3052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI26973208800000X
WI2697320208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
340012140OtherRR MEDICARE
WI31392600Medicaid
WI000182021Medicare PIN
WI000181934Medicare PIN
WI31392600Medicaid
340012140OtherRR MEDICARE
WI000101351Medicare PIN