Provider Demographics
NPI:1689665051
Name:DIWAN, KANTA (MD)
Entity Type:Individual
Prefix:DR
First Name:KANTA
Middle Name:
Last Name:DIWAN
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 1:211 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-3019
Mailing Address - Country:US
Mailing Address - Phone:610-565-2754
Mailing Address - Fax:610-565-8493
Practice Address - Street 1:211 N MONROE ST
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-3019
Practice Address - Country:US
Practice Address - Phone:610-565-2754
Practice Address - Fax:610-565-8493
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036633L208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0900467Medicaid
PAB34751Medicare UPIN
PA066014Medicare ID - Type Unspecified