Provider Demographics
NPI:1235201898
Name:DIVAN, TODD LEE (DPM)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:LEE
Last Name:DIVAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 E REELFOOT AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-5812
Mailing Address - Country:US
Mailing Address - Phone:731-885-0220
Mailing Address - Fax:731-885-0216
Practice Address - Street 1:1415 E REELFOOT AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-5812
Practice Address - Country:US
Practice Address - Phone:731-885-0220
Practice Address - Fax:731-885-0216
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004761213ES0131X
TN734213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016-004-761Medicaid
IL480019679OtherPALMETTO - MEDICARE
IL09206992OtherBCBS INSURANCE
IL480019679OtherPALMETTO - MEDICARE
TN10370G7165Medicare UPIN
TN103I487163Medicare UPIN
IL016-004-761Medicaid