MEDICARE: TIMOTHY D DIVENS MD

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	1050545	IN
2	2085R0204X	Vascular & Interventional Radiology Physician	01050545A	IN
3	2085R0202X	Diagnostic Radiology Physician	01050545A	IN

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	300124562	OTHER	IN	RAILROAD MEDICARE
2	P00024122	OTHER		RAILROAD MEDICARE
4	300138597	OTHER		RAILROAD MEDICARE
5	P00023582	OTHER		RAILROAD MEDICARE
6	P00023583	OTHER		RAILROAD MEDICARE
7	P00023584	OTHER		RAILROAD MEDICARE
8	P00024079	OTHER		RAILROAD MEDICARE
9	P00024419	OTHER		RAILROAD MEDICARE
10	P00023585	OTHER		RAILROAD MEDICARE
11	P00024260	OTHER		RAILROAD MEDICARE
12	P00024421	OTHER		RAILROAD MEDICARE
13	P00346514	OTHER		RAILROAD MEDICARE
15	P000233634	OTHER		RAILROAD MEDICARE
16	P00023634	OTHER		RAILROAD MEDICARE
17	P00024059	OTHER		RAILROAD MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	000000204809	OTHER	IN	ANTHEM
14	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1164416475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY D DIVENS MD

Provider Business Mailing Address
First Line	:	9998 CROSSPOINT BLVD
Second Line	:	STE 200
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46256-3307
Country	:	US
Telephone Number	:	317-579-2150
Fax Number	:	317-579-2130

Provider Business Practice Location Address
First Line	:	9998 CROSSPOINT BLVD STE 200
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46256-3307
Country	:	US
Telephone Number	:	317-579-2150
Fax Number	:	317-579-2130

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2005
Last Update Date	:	12/24/2020