Provider Demographics
NPI:1134104037
Name:KEDLAYA, DIVAKARA (MD)
Entity Type:Individual
Prefix:
First Name:DIVAKARA
Middle Name:
Last Name:KEDLAYA
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 1:1925 E ORMAN AVE
Mailing Address - Street 2:SUITE A235
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3537
Mailing Address - Country:US
Mailing Address - Phone:719-557-3666
Mailing Address - Fax:719-557-3633
Practice Address - Street 1:1925 E ORMAN AVE
Practice Address - Street 2:SUITE A235
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3537
Practice Address - Country:US
Practice Address - Phone:719-557-3666
Practice Address - Fax:719-557-3633
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA055622208100000X
IL036147433208100000X
CO44383208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO42809223Medicaid
CO42809223Medicaid