MEDICARE: DR. DIVYA KRISHNAMOORTHY MD

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	C54901	CA
2	2084P0804X	Child & Adolescent Psychiatry Physician	C54901	CA

General Provider Information

NPI Number	:	1194742825
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIVYA KRISHNAMOORTHY MD

Provider Business Mailing Address
First Line	:	PO BOX 3222
Second Line	:
City	:	RANCHO SANTA FE
State	:	CA
Zip	:	92067-3222
Country	:	US
Telephone Number	:	206-965-0030
Fax Number	:

Provider Business Practice Location Address
First Line	:	762 CYPRESS ST
Second Line	:
City	:	SAN DIMAS
State	:	CA
Zip	:	91773-3505
Country	:	US
Telephone Number	:	909-599-1227
Fax Number	:	206-299-9789

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

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	12/11/2023

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