Healthcare Provider Details

I. General information

NPI: 1154515963
Provider Name (Legal Business Name): DIVYA VATS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2007
Last Update Date: 12/08/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD MAIL STOP # 90
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

4650 W SUNSET BLVD MAIL STOP # 90
LOS ANGELES CA
90027-6062
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-2178
  • Fax: 323-361-1172
Mailing address:
  • Phone: 323-361-2178
  • Fax: 323-361-1172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberR8236
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207SG0202X
TaxonomyClinical Biochemical Genetics Physician
License NumberA107303
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: