Healthcare Provider Details

I. General information

NPI: 1831935055
Provider Name (Legal Business Name): DIVYA PATEL OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 E 162ND ST
SOUTH HOLLAND IL
60473-2465
US

IV. Provider business mailing address

313 W WOLF POINT PLZ UNIT 3106
CHICAGO IL
60654-8910
US

V. Phone/Fax

Practice location:
  • Phone: 732-887-9235
  • Fax:
Mailing address:
  • Phone: 732-887-9235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA3010
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046012078
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18004699A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: