Provider Demographics
NPI:1134794050
Name:MAMOOTIL, DIVYA (MD)
Entity type:Individual
Prefix:
First Name:DIVYA
Middle Name:
Last Name:MAMOOTIL
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 1:300 SEYMOUR AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1343
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 SEYMOUR AVE STE 202
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-1343
Practice Address - Country:US
Practice Address - Phone:203-732-2651
Practice Address - Fax:203-732-2654
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT231028207RR0500X
390200000X
CT82939207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program