Provider Demographics
NPI:1215125208
Name:DIVEKAR, ABHAY ASHOK (MD, MBBS)
Entity type:Individual
Prefix:DR
First Name:ABHAY
Middle Name:ASHOK
Last Name:DIVEKAR
Suffix:
Gender:M
Credentials:MD, MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5323 HARRY HINES BLVD STOP 7200
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-9063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5323 HARRY HINES BLVD STOP 7200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-9063
Practice Address - Country:US
Practice Address - Phone:214-456-2333
Practice Address - Fax:214-456-2333
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-394162080P0202X
MO20160329202080P0202X
IA374992080P0202X
CODR.00572612080P0202X
TXT34612080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA71365OtherWELLMARK BCBS
IAI21611Medicare PIN