Provider Demographics
NPI:1528498565
Name:PATEL, DIVYA (OD)
Entity type:Individual
Prefix:
First Name:DIVYA
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 WILMA RUDOLPH BLVD STE 665
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5063
Mailing Address - Country:US
Mailing Address - Phone:931-552-4455
Mailing Address - Fax:931-552-8999
Practice Address - Street 1:2801 WILMA RUDOLPH BLVD STE 665
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5063
Practice Address - Country:US
Practice Address - Phone:931-552-4455
Practice Address - Fax:931-552-8999
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-12
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN3136152W00000X
TN3136152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist