Provider Demographics
NPI:1881868800
Name:DIVINE, YASMIN (MD)
Entity type:Individual
Prefix:
First Name:YASMIN
Middle Name:
Last Name:DIVINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:YASMIN
Other - Middle Name:
Other - Last Name:ISSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1289
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33601-1289
Mailing Address - Country:US
Mailing Address - Phone:813-844-7000
Mailing Address - Fax:
Practice Address - Street 1:409 BAYSHORE BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2707
Practice Address - Country:US
Practice Address - Phone:813-844-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA239450207QG0300X
FLME111615207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110095071AMedicaid
MA001551602Medicare PIN