Provider Demographics
NPI:1740214675
Name:DIVEN, DAYNA GWINUP (MD)
Entity type:Individual
Prefix:
First Name:DAYNA
Middle Name:GWINUP
Last Name:DIVEN
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 1:1601 RIO GRANDE ST STE 340
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-1162
Mailing Address - Country:US
Mailing Address - Phone:512-324-8960
Mailing Address - Fax:
Practice Address - Street 1:5103 KYLE CENTER DR
Practice Address - Street 2:SUITE 104
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6163
Practice Address - Country:US
Practice Address - Phone:512-504-0855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2340207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124705808Medicaid
TX124705809Medicaid
TX8L15384Medicare PIN
TXE41370Medicare UPIN
TX124705808Medicaid