Provider Demographics
NPI:1629418694
Name:GOPALAN, DIVYANJALI (MD)
Entity Type:Individual
Prefix:
First Name:DIVYANJALI
Middle Name:
Last Name:GOPALAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 S PINE ISLAND RD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3923
Mailing Address - Country:US
Mailing Address - Phone:954-493-6496
Mailing Address - Fax:954-493-6726
Practice Address - Street 1:6181 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-2227
Practice Address - Country:US
Practice Address - Phone:954-493-6496
Practice Address - Fax:954-493-6726
Is Sole Proprietor?:No
Enumeration Date:2013-07-05
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT052271208000000X
FLME141078208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104706100Medicaid