Provider Demographics
NPI:1477086122
Name:MANOHARA, DIVYA
Entity Type:Individual
Prefix:
First Name:DIVYA
Middle Name:
Last Name:MANOHARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 PEACH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2700
Mailing Address - Country:US
Mailing Address - Phone:805-369-8860
Mailing Address - Fax:
Practice Address - Street 1:1035 PEACH ST STE 301
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2700
Practice Address - Country:US
Practice Address - Phone:805-369-8860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA176136207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine