Provider Demographics
NPI:1376635409
Name:DIVAKER, REZIA CATHERINE SHOBHANA (MD)
Entity Type:Individual
Prefix:
First Name:REZIA
Middle Name:CATHERINE SHOBHANA
Last Name:DIVAKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHOBHANA
Other - Middle Name:REZIA CATHERINE
Other - Last Name:JOSEPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:13506 SUMMERPORT VILLAGE PKWY
Mailing Address - Street 2:STE# 334
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-7366
Mailing Address - Country:US
Mailing Address - Phone:352-383-8384
Mailing Address - Fax:
Practice Address - Street 1:6551 N ORANGE BLOSSOM TRL
Practice Address - Street 2:STE# 229
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-7013
Practice Address - Country:US
Practice Address - Phone:352-383-8384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96675208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008731900Medicaid
FL56693OtherBCBS