Provider Demographics
NPI:1801425905
Name:DIVAKARUNI, VENKATA LAAVANYA (MD)
Entity type:Individual
Prefix:
First Name:VENKATA LAAVANYA
Middle Name:
Last Name:DIVAKARUNI
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 1:10085 RED RUN BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-4811
Mailing Address - Country:US
Mailing Address - Phone:410-581-7804
Mailing Address - Fax:
Practice Address - Street 1:10085 RED RUN BLVD STE 105
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-4811
Practice Address - Country:US
Practice Address - Phone:410-581-7804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD98286207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD221376100Medicaid