Provider Demographics
NPI:1689325169
Name:DIVAKARAN, DALTON
Entity Type:Individual
Prefix:
First Name:DALTON
Middle Name:
Last Name:DIVAKARAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2509 DURANGO DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-5013
Mailing Address - Country:US
Mailing Address - Phone:678-777-6199
Mailing Address - Fax:
Practice Address - Street 1:2509 DURANGO DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-5013
Practice Address - Country:US
Practice Address - Phone:678-777-6199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-15
Last Update Date:2022-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX817979163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse