Provider Demographics
NPI:1093389124
Name:MADISETTY, DIVYA BHANU SREE (MD)
Entity Type:Individual
Prefix:
First Name:DIVYA BHANU SREE
Middle Name:
Last Name:MADISETTY
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 1:2101 N. WATERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404
Mailing Address - Country:US
Mailing Address - Phone:909-644-5892
Mailing Address - Fax:
Practice Address - Street 1:DIGNITY HEALTH, ST. BERNARDINE MEDICAL CENTER, 2101 N.
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404
Practice Address - Country:US
Practice Address - Phone:909-644-5892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2022-10-12
Deactivation Date:2022-09-26
Deactivation Code:
Reactivation Date:2022-10-12
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program