Provider Demographics
NPI:1164161139
Name:MANIVANNAN, DIVYA (MD)
Entity type:Individual
Prefix:DR
First Name:DIVYA
Middle Name:
Last Name:MANIVANNAN
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 1:14860 ROSCOE BLVD
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-4665
Mailing Address - Country:US
Mailing Address - Phone:818-904-3132
Mailing Address - Fax:
Practice Address - Street 1:11333 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1116
Practice Address - Country:US
Practice Address - Phone:818-365-9531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-29
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA199096207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program