Provider Demographics
NPI:1639106610
Name:RAVIENDRAN, DIVYA T (MD)
Entity Type:Individual
Prefix:
First Name:DIVYA
Middle Name:T
Last Name:RAVIENDRAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIVYA
Other - Middle Name:
Other - Last Name:RAJ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1 EMBARCADERO CTR STE 1900
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94111-3723
Mailing Address - Country:US
Mailing Address - Phone:415-658-6791
Mailing Address - Fax:
Practice Address - Street 1:3151 CROW CANYON PL
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1359
Practice Address - Country:US
Practice Address - Phone:888-663-6331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81826207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA81826OtherM.D LICENSE
CAA81826OtherM.D LICENSE