Provider Demographics
NPI:1336643857
Name:DIVYA, VENU GOPAL
Entity Type:Individual
Prefix:
First Name:VENU GOPAL
Middle Name:
Last Name:DIVYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41465 SPECKLED ALDER CT
Mailing Address - Street 2:
Mailing Address - City:ALDIE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-6036
Mailing Address - Country:US
Mailing Address - Phone:267-275-1219
Mailing Address - Fax:
Practice Address - Street 1:41465 SPECKLED ALDER CT
Practice Address - Street 2:
Practice Address - City:ALDIE
Practice Address - State:VA
Practice Address - Zip Code:20105-6036
Practice Address - Country:US
Practice Address - Phone:267-275-1219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211543225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist