Organization
DIVI MD PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
THULASI S DIVI MD (OWNER/PRESIDENT)
(248) 528-1555
Entity
Organization
Contact information
Practice address
20755 GREENFIELD RD, STE #1004, SOUTHFIELD, MI 48075-5403
(248) 424-5090
(248) 424-5091
Mailing address
20755 GREENFIELD ROAD, STE # 1004, SOUTHFIELD, MI 48075-5411
(248) 424-5090
(248) 424-5091
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
4301062122
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
23D0988999
CLIA CERTIFICATE
MI
05
—
4226454
—
MI
Enumeration date
07/26/2006
Last updated
12/14/2009
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