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General NPI Number Information
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NPI Number | 1124259858
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Entity Type | Individual
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Provider Name | DIVYA MANGALA KESTUR RAJASEKHAR MD
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Gender | Female
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Dates
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Enumeration Date | 07/29/2009
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Last Update Date | 09/06/2019
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Provider Practice Location Address
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Address Line | 1185 MAIN ST STE 4
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City | WILLIMANTIC
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State | CT
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Zip | 06226-2093
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Country | US
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Telephone | 860-423-7558
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Fax | 860-423-4694
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Provider Business Mailing Address
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Address Line | 273 FAIRWAY XING
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City | GLASTONBURY
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State | CT
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Zip | 06033-1465
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Country | US
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Telephone | 469-487-9988
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 53382
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License Number State | CT
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