MEDICARE: DR. VENU DIVI M.D.

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	207Y00000X	Otolaryngology Physician	C55612	CA

General Provider Information

NPI Number	:	1245390228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VENU DIVI M.D.

Provider Business Mailing Address
First Line	:	21320 HAWTHORNE BLVD
Second Line	:	SUITE 119
City	:	TORRANCE
State	:	CA
Zip	:	90503-5606
Country	:	US
Telephone Number	:	310-540-2111
Fax Number	:	310-944-9295

Provider Business Practice Location Address
First Line	:	350 W 5TH ST STE 209
Second Line	:
City	:	SAN PEDRO
State	:	CA
Zip	:	90731-2752
Country	:	US
Telephone Number	:	310-521-6386
Fax Number	:	310-521-6387

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

Provider Enumeration Date	:	12/11/2006
Last Update Date	:	06/13/2019

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