Healthcare Provider Details

I. General information

NPI: 1437437613
Provider Name (Legal Business Name): DIVYA MALLAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2011
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 MAIDEN LN RM 1204
NEW YORK NY
10038-4721
US

IV. Provider business mailing address

80 MAIDEN LN RM 1204
NEW YORK NY
10038-4721
US

V. Phone/Fax

Practice location:
  • Phone: 212-427-8761
  • Fax: 212-427-8762
Mailing address:
  • Phone: 212-427-8761
  • Fax: 212-427-8762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA123488
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number103660-875
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number328761
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: