Provider Demographics
NPI:1710327580
Name:DVIVEDI, MIRA N (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRA
Middle Name:N
Last Name:DVIVEDI
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 1:250 W KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4371
Mailing Address - Country:US
Mailing Address - Phone:217-872-3800
Mailing Address - Fax:217-872-0849
Practice Address - Street 1:250 W KENWOOD AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4371
Practice Address - Country:US
Practice Address - Phone:217-872-3800
Practice Address - Fax:217-872-0849
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-064054207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine