Healthcare Provider Details

I. General information

NPI: 1164161139
Provider Name (Legal Business Name): DIVYA MANIVANNAN M.D..
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2022
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11333 SEPULVEDA BLVD
MISSION HILLS CA
91345-1116
US

IV. Provider business mailing address

2675 WINKLER AVE STE 200
FORT MYERS FL
33901-9328
US

V. Phone/Fax

Practice location:
  • Phone: 818-869-7254
  • Fax: 818-869-1723
Mailing address:
  • Phone: 877-856-3774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME183487
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: