Provider Demographics
NPI:1972732576
Name:GODBOLE, KETAN DEEPAK (MD)
Entity type:Individual
Prefix:DR
First Name:KETAN
Middle Name:DEEPAK
Last Name:GODBOLE
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:1145 S UTICA AVE
Mailing Address - Street 2:STE 460
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4000
Mailing Address - Country:US
Mailing Address - Phone:918-579-5749
Mailing Address - Fax:918-579-5762
Practice Address - Street 1:1145 S UTICA AVE
Practice Address - Street 2:STE 460
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4000
Practice Address - Country:US
Practice Address - Phone:918-579-5749
Practice Address - Fax:918-579-5762
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2015-07-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OK29548207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200481220AMedicaid