Individual
DIVYA GOUTAM VIJENDRA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
433 W HIGH ST, BRYAN, OH 43506-1690
(419) 636-1131
(419) 636-3100
Mailing address
433 W HIGH ST, BRYAN, OH 43506-1690
(419) 636-1131
(419) 636-3100
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
35-084674
OH
207RG0300X
Geriatric Medicine (Internal Medicine) Physician
35084674
OH
207RX0202X
Medical Oncology Physician
Primary
35084674
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2491683
—
OH
Enumeration date
10/16/2006
Last updated
08/20/2020
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