Provider Demographics
NPI:1992841399
Name:SRIKUMARAN, DIVYA (MD)
Entity Type:Individual
Prefix:DR
First Name:DIVYA
Middle Name:
Last Name:SRIKUMARAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIVYA
Other - Middle Name:
Other - Last Name:GUPTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 64481
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4481
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4940 EASTERN AVE
Practice Address - Street 2:JOHNS HOPKINS BAYVIEW MEDICAL CENTER
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2735
Practice Address - Country:US
Practice Address - Phone:410-550-2360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2013-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP19723207W00000X
MDD69428207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD418046100Medicaid
MD418046100Medicaid