Provider Demographics
NPI:1164416475
Name:DIVENS, TIMOTHY D (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
Last Name:DIVENS
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 1:9998 CROSSPOINT BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3307
Mailing Address - Country:US
Mailing Address - Phone:317-579-2150
Mailing Address - Fax:317-579-2130
Practice Address - Street 1:9998 CROSSPOINT BLVD STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-3307
Practice Address - Country:US
Practice Address - Phone:317-579-2150
Practice Address - Fax:317-579-2130
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10505452085R0202X
IN01050545A2085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300124562OtherRAILROAD MEDICARE
P00024122OtherRAILROAD MEDICARE
IN000000204809OtherANTHEM
300138597OtherRAILROAD MEDICARE
P00023582OtherRAILROAD MEDICARE
P00023583OtherRAILROAD MEDICARE
P00023584OtherRAILROAD MEDICARE
P00024079OtherRAILROAD MEDICARE
P00024419OtherRAILROAD MEDICARE
P00023585OtherRAILROAD MEDICARE
P00024260OtherRAILROAD MEDICARE
P00024421OtherRAILROAD MEDICARE
P00346514OtherRAILROAD MEDICARE
IN20025310AMedicaid
P000233634OtherRAILROAD MEDICARE
P00023634OtherRAILROAD MEDICARE
P00024059OtherRAILROAD MEDICARE
1515600Medicare PIN
IN300124562OtherRAILROAD MEDICARE
P00023634OtherRAILROAD MEDICARE
P00346514OtherRAILROAD MEDICARE