Provider Demographics
NPI:1902936586
Name:DIVAKARUNI, ANURADHA (MD)
Entity Type:Individual
Prefix:
First Name:ANURADHA
Middle Name:
Last Name:DIVAKARUNI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3915
Mailing Address - Country:US
Mailing Address - Phone:219-836-9677
Mailing Address - Fax:219-836-0688
Practice Address - Street 1:1730 45TH AVE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3915
Practice Address - Country:US
Practice Address - Phone:219-836-9677
Practice Address - Fax:219-836-0688
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042616207UN0901X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100382300Medicaid
IL90000999OtherBCBSIL
IN000000320576OtherANTHEM
IN100382300Medicaid
IL90000999OtherBCBSIL
INE74604Medicare UPIN