Provider Demographics
NPI:1528708500
Name:GOPAL, DIVYA DINES (PA-C)
Entity type:Individual
Prefix:MS
First Name:DIVYA
Middle Name:DINES
Last Name:GOPAL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13601 WOODFOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77015-2908
Mailing Address - Country:US
Mailing Address - Phone:713-330-4325
Mailing Address - Fax:
Practice Address - Street 1:13601 WOODFOREST BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77015-2908
Practice Address - Country:US
Practice Address - Phone:713-330-4325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.008847363A00000X
GA10865363A00000X
TXPA15619363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant