Provider Demographics
NPI:1972852333
Name:RAGHAVAN, DIVYA (MD)
Entity type:Individual
Prefix:
First Name:DIVYA
Middle Name:
Last Name:RAGHAVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30N 1900 E 4R312
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0006
Mailing Address - Country:US
Mailing Address - Phone:801-581-8193
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:CARLE FORUM, LL
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-2500
Practice Address - Country:US
Practice Address - Phone:217-383-3110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-31
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125061317207R00000X
UT9423487-1205207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine