Basic Information
| Provider Information | |||||||||
| NPI: | 1730223934 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOSHI | ||||||||
| FirstName: | DIVYA | ||||||||
| MiddleName: | BIREN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 116156 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303686156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4703250100 | ||||||||
| FaxNumber: | 4703250193 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 OLD NORCROSS RD | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300468716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783125250 | ||||||||
| FaxNumber: | 6784427648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2007 | ||||||||
| LastUpdateDate: | 07/16/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 54228 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 950348552A | 05 | GA | MEDICAID |