Provider Demographics
NPI:1689803124
Name:MUTHAPPA, DIVYA BACHARANIANDA (MD)
Entity Type:Individual
Prefix:DR
First Name:DIVYA
Middle Name:BACHARANIANDA
Last Name:MUTHAPPA
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 1:19260 STONE OAK PKWY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3365
Mailing Address - Country:US
Mailing Address - Phone:210-402-3456
Mailing Address - Fax:
Practice Address - Street 1:19260 STONE OAK PKWY STE 105
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258
Practice Address - Country:US
Practice Address - Phone:210-402-3456
Practice Address - Fax:210-402-3233
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP5692207R00000X
PAMT196124207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX322793601Medicaid