Provider Demographics
NPI:1174783567
Name:GODHWANI, SANJAY (MD)
Entity type:Individual
Prefix:
First Name:SANJAY
Middle Name:
Last Name:GODHWANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6144 ROUTE 25A STE 13
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-2008
Mailing Address - Country:US
Mailing Address - Phone:631-886-2844
Mailing Address - Fax:631-886-2842
Practice Address - Street 1:6144 ROUTE 25A STE 13
Practice Address - Street 2:
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792-2008
Practice Address - Country:US
Practice Address - Phone:631-886-2844
Practice Address - Fax:631-886-2842
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266326207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03497523Medicaid