Healthcare Provider Details

I. General information

NPI: 1134104037
Provider Name (Legal Business Name): DIVAKARA KEDLAYA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9250 E COSTILLA AVE STE 540
GREENWOOD VILLAGE CO
80112-3648
US

IV. Provider business mailing address

9250 E COSTILLA AVE STE 540
GREENWOOD VILLAGE CO
80112-3648
US

V. Phone/Fax

Practice location:
  • Phone: 206-449-3557
  • Fax:
Mailing address:
  • Phone: 206-449-3557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberA055622
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036147433
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number44383
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: