Healthcare Provider Details

I. General information

NPI: 1255781217
Provider Name (Legal Business Name): DIVYESH REDDY NEMAKAYALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 SERVICE RD RM A225
EAST LANSING MI
48824-7015
US

IV. Provider business mailing address

788 SERVICE RD RM B301
EAST LANSING MI
48824-7013
US

V. Phone/Fax

Practice location:
  • Phone: 517-353-4941
  • Fax: 517-432-3145
Mailing address:
  • Phone: 517-353-5100
  • Fax: 517-432-2759

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036166094
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number25MA11856000
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301109731
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number89779
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01090619A
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberC1-0027053
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: