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General NPI Number Information
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NPI Number | 1366972101
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Entity Type | Individual
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Provider Name | DIVYA RAJENDRA VANKAWALA OD
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Gender | Female
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Dates
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Enumeration Date | 06/14/2017
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Last Update Date | 01/13/2020
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Provider Practice Location Address
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Address Line | 10701 EAST BOULEVARD LOUIS STOKES VAMC
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City | CLEVELAND
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State | OH
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Zip | 44106
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Country | US
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Telephone | 216-791-3800
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Fax |
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Provider Business Mailing Address
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Address Line | 2724 VELA
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City | GRAND PRAIRIE
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State | TX
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Zip | 75054-5537
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Country | US
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Telephone | 817-832-7719
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 9322TG
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License Number State | TX
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