Healthcare Provider Details

I. General information

NPI: 1376422915
Provider Name (Legal Business Name): DIVYA NAIK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2025
Last Update Date: 08/28/2025
Certification Date: 08/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE STE 1M107
COLTON CA
92324-1801
US

IV. Provider business mailing address

840 BAKER ST APT A112
COSTA MESA CA
92626-4337
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-2178
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: