Provider Demographics
NPI:1720265929
Name:MOODALBAIL, DIVYA
Entity Type:Individual
Prefix:
First Name:DIVYA
Middle Name:
Last Name:MOODALBAIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIVYA
Other - Middle Name:
Other - Last Name:MOODALBAIL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:710 LAWRENCE EXPY
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-5173
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:710 LAWRENCE EXPY
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95051-5173
Practice Address - Country:US
Practice Address - Phone:408-851-1240
Practice Address - Fax:408-851-1240
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA2080P0210X
DEC100104822080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology