Provider Demographics
NPI:1679795728
Name:ADUSUMILLI, DIVYA (DD)
Entity Type:Individual
Prefix:DR
First Name:DIVYA
Middle Name:
Last Name:ADUSUMILLI
Suffix:
Gender:F
Credentials:DD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 E 72ND ST
Mailing Address - Street 2:APT 1CD2D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4011
Mailing Address - Country:US
Mailing Address - Phone:212-734-2959
Mailing Address - Fax:
Practice Address - Street 1:285 FORT WASHINGTON AVE
Practice Address - Street 2:CD
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1206
Practice Address - Country:US
Practice Address - Phone:212-795-9675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052896-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02622604Medicaid
NY02820973Medicaid