Provider Demographics
NPI:1306881321
Name:DIVIJA NEUROLOGY CENTER, PA
Entity type:Organization
Organization Name:DIVIJA NEUROLOGY CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BHUVANA PRASAD
Authorized Official - Middle Name:L
Authorized Official - Last Name:MANDALAPU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-617-1841
Mailing Address - Street 1:8700 MANCHACA RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-5371
Mailing Address - Country:US
Mailing Address - Phone:512-617-1841
Mailing Address - Fax:512-280-6750
Practice Address - Street 1:8700 MANCHACA RD
Practice Address - Street 2:SUITE 205
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-5371
Practice Address - Country:US
Practice Address - Phone:512-617-1841
Practice Address - Fax:512-280-6750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9606174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0019NCOtherBCBS
TX0019NCOtherBCBS