Healthcare Provider Details

I. General information

NPI: 1942404298
Provider Name (Legal Business Name): DIVAYA BHUTANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 FORT WASHINGTON AVE
NEW YORK NY
10032-3729
US

IV. Provider business mailing address

630 W 168TH ST # 4
NEW YORK NY
10032-3725
US

V. Phone/Fax

Practice location:
  • Phone: 646-317-4805
  • Fax: 212-305-8111
Mailing address:
  • Phone: 646-317-4805
  • Fax: 212-305-8111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number4301095690
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301095690
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number290637
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberE-5229
License Number StateAR
# 5
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number290637
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: