Provider Demographics
NPI:1528419587
Name:SIVAKUMAR, DIVYA (DO)
Entity Type:Individual
Prefix:
First Name:DIVYA
Middle Name:
Last Name:SIVAKUMAR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 WENTZVILLE PKWY
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3437
Mailing Address - Country:US
Mailing Address - Phone:636-425-4673
Mailing Address - Fax:
Practice Address - Street 1:1021 WENTZVILLE PKWY
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3437
Practice Address - Country:US
Practice Address - Phone:636-425-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20210467622084N0400X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1528419587Medicaid