Basic Information
| Provider Information | |||||||||
| NPI: | 1043625445 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIVAN | ||||||||
| FirstName: | VIDITA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3520 SW 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666062806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7853549591 | ||||||||
| FaxNumber: | 7853540542 | ||||||||
| Practice Location | |||||||||
| Address1: | 3520 SW 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | TOPEKA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 666062806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7853549591 | ||||||||
| FaxNumber: | 7853540542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2014 | ||||||||
| LastUpdateDate: | 03/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RE0101X | 04-43416 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
No ID Information.