Healthcare Provider Details

I. General information

NPI: 1124385547
Provider Name (Legal Business Name): DIVYA ULLAL SIDHU M.D., M.P.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2012
Last Update Date: 12/13/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

568 E HERNDON AVE STE 101
FRESNO CA
93720-2989
US

IV. Provider business mailing address

568 E HERNDON AVE STE 101
FRESNO CA
93720-2989
US

V. Phone/Fax

Practice location:
  • Phone: 559-224-7990
  • Fax: 559-224-5617
Mailing address:
  • Phone: 559-251-7505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA170542
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: