Provider Demographics
NPI:1083026108
Name:PANNEERSELVAM, DIVYA
Entity Type:Individual
Prefix:
First Name:DIVYA
Middle Name:
Last Name:PANNEERSELVAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1357
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-1357
Mailing Address - Country:US
Mailing Address - Phone:239-278-3600
Mailing Address - Fax:239-278-3857
Practice Address - Street 1:316 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-1710
Practice Address - Country:US
Practice Address - Phone:239-226-4592
Practice Address - Fax:239-458-0623
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME123954208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014953400Medicaid
FL014953400Medicaid