=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720291404
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SVASTIJAYA DAVIRATANASILPA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2007
-----------------------------------------------------
Last Update Date | 06/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1198 S GOVERNORS AVE STE B100
-----------------------------------------------------
City | DOVER
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19904-6930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-424-3694
-----------------------------------------------------
Fax | 302-424-3697
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4923 OGLETOWN STANTON RD SUITE 200
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19713-2081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-225-0451
-----------------------------------------------------
Fax | 302-225-0470
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | C1-0008993
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MT184883
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------