Provider Demographics
NPI:1124863824
Name:AMPOLU, DIVYA (MD)
Entity type:Individual
Prefix:MRS
First Name:DIVYA
Middle Name:
Last Name:AMPOLU
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 FRANKLIN STREET
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706
Mailing Address - Country:US
Mailing Address - Phone:203-709-6424
Mailing Address - Fax:
Practice Address - Street 1:56 FRANKLIN STREET
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706
Practice Address - Country:US
Practice Address - Phone:203-709-6424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-26
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program