Provider Demographics
NPI:1639675572
Name:MADHUSUDHAN, DIVYA
Entity Type:Individual
Prefix:
First Name:DIVYA
Middle Name:
Last Name:MADHUSUDHAN
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 1:5217 TULIP LEAF CT
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-6112
Mailing Address - Country:US
Mailing Address - Phone:540-878-8329
Mailing Address - Fax:
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:800-879-2467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-31
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMT227979207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program