Provider Demographics
NPI:1023548948
Name:DIVINE PROSPERITY LLC
Entity Type:Organization
Organization Name:DIVINE PROSPERITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KISHORE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:855-541-2862
Mailing Address - Street 1:15317 GRAYSON DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-2601
Mailing Address - Country:US
Mailing Address - Phone:855-541-2862
Mailing Address - Fax:405-716-4808
Practice Address - Street 1:1104 E STATE HIGHWAY 152 UNIT 1
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-5116
Practice Address - Country:US
Practice Address - Phone:405-563-3998
Practice Address - Fax:405-563-3998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-13
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25877208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty