Healthcare Provider Details

I. General information

NPI: 1376635409
Provider Name (Legal Business Name): REZIA CATHERINE SHOBHANA DIVAKER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHOBHANA REZIA CATHERINE JOSEPH MD

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 08/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6551 N ORANGE BLOSSOM TRL STE# 229
MOUNT DORA FL
32757-7013
US

IV. Provider business mailing address

13506 SUMMERPORT VILLAGE PKWY STE# 334
WINDERMERE FL
34786-7366
US

V. Phone/Fax

Practice location:
  • Phone: 352-383-8384
  • Fax:
Mailing address:
  • Phone: 352-383-8384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME96675
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: