Provider Demographics
NPI:1073361176
Name:DIVECHA, SURAJ (MD)
Entity type:Individual
Prefix:DR
First Name:SURAJ
Middle Name:
Last Name:DIVECHA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31662 ISLE ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-2824
Mailing Address - Country:US
Mailing Address - Phone:949-516-8133
Mailing Address - Fax:
Practice Address - Street 1:96 15TH ST. NE, SUITE 104
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273
Practice Address - Country:US
Practice Address - Phone:276-679-7457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116038959207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine