Provider Demographics
NPI:1386726552
Name:DIWAN, LAXMIDHAR (MD)
Entity type:Individual
Prefix:DR
First Name:LAXMIDHAR
Middle Name:
Last Name:DIWAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6254 97TH PL
Mailing Address - Street 2:SUITE 2H
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1346
Mailing Address - Country:US
Mailing Address - Phone:718-271-7700
Mailing Address - Fax:718-271-4490
Practice Address - Street 1:6254 97TH PL
Practice Address - Street 2:SUITE 2H
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-1346
Practice Address - Country:US
Practice Address - Phone:718-271-7700
Practice Address - Fax:718-271-4490
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153779207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE36445Medicare UPIN
NY74942CMedicare ID - Type UnspecifiedGHI MEDICARE