Provider Demographics
NPI:1689875825
Name:SRIVASTAVA, DIVYA (MD)
Entity Type:Individual
Prefix:DR
First Name:DIVYA
Middle Name:
Last Name:SRIVASTAVA
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:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-2400
Mailing Address - Fax:
Practice Address - Street 1:5939 HARRY HINES BLVD
Practice Address - Street 2:UTSW DEPARTMENT OF DERMATOLOGY
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-6246
Practice Address - Country:US
Practice Address - Phone:214-645-8947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301087723207N00000X
TXN3326207ND0101X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology