Healthcare Provider Details

I. General information

NPI: 1851852081
Provider Name (Legal Business Name): DIVYA DEVABHAKTUNI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2019
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S ORANGE AVE STE 103
ORLANDO FL
32806-2946
US

IV. Provider business mailing address

1717 S ORANGE AVE STE 103
ORLANDO FL
32806-2946
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-4344
  • Fax: 321-843-1753
Mailing address:
  • Phone: 321-841-4344
  • Fax: 321-843-1753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME176972
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: