Provider Demographics
NPI:1194742825
Name:KRISHNAMOORTHY, DIVYA (MD)
Entity type:Individual
Prefix:DR
First Name:DIVYA
Middle Name:
Last Name:KRISHNAMOORTHY
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:PO BOX 3222
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA FE
Mailing Address - State:CA
Mailing Address - Zip Code:92067-3222
Mailing Address - Country:US
Mailing Address - Phone:206-965-0030
Mailing Address - Fax:
Practice Address - Street 1:762 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3505
Practice Address - Country:US
Practice Address - Phone:909-599-1227
Practice Address - Fax:206-299-9789
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC549012084P0800X, 2084P0804X, 2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry