Provider Demographics
NPI:1588977557
Name:DIVAN, AMMAR Y (MD)
Entity type:Individual
Prefix:DR
First Name:AMMAR
Middle Name:Y
Last Name:DIVAN
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 1:245 S GARY AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2200
Mailing Address - Country:US
Mailing Address - Phone:630-933-4550
Mailing Address - Fax:630-933-2200
Practice Address - Street 1:245 S GARY AVE STE 100
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2200
Practice Address - Country:US
Practice Address - Phone:630-933-4550
Practice Address - Fax:630-933-2200
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123274207L00000X, 207LP2900X
VA0101247908207L00000X
MDD71131207L00000X
GA068143207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology