Provider Demographics
NPI:1851658041
Name:RAO, DIVYA ANNAM (MD)
Entity Type:Individual
Prefix:
First Name:DIVYA
Middle Name:ANNAM
Last Name:RAO
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:325 MEDICAL PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-2457
Practice Address - Country:US
Practice Address - Phone:864-797-9550
Practice Address - Fax:864-797-9555
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC38786207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC387860Medicaid
SC387860Medicaid