Healthcare Provider Details

I. General information

NPI: 1245390228
Provider Name (Legal Business Name): VENU DIVI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W 5TH ST STE 209
SAN PEDRO CA
90731-2752
US

IV. Provider business mailing address

21320 HAWTHORNE BLVD SUITE 119
TORRANCE CA
90503-5606
US

V. Phone/Fax

Practice location:
  • Phone: 310-521-6386
  • Fax: 310-521-6387
Mailing address:
  • Phone: 310-540-2111
  • Fax: 310-944-9295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberC55612
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: