Provider Demographics
NPI:1780824037
Name:DIVIS, MARA (DO)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:DIVIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-1368
Mailing Address - Country:US
Mailing Address - Phone:773-395-7400
Mailing Address - Fax:773-395-9608
Practice Address - Street 1:5501 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-1368
Practice Address - Country:US
Practice Address - Phone:733-957-4007
Practice Address - Fax:773-395-9608
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-26
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003631A207Q00000X
OH58.002346207Q00000X
IL036129431207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine