Provider Demographics
NPI:1881868800
Name:DIVINE, YASMIN (MD)
Entity type:Individual
Prefix:
First Name:YASMIN
Middle Name:
Last Name:DIVINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:YASMIN
Other - Middle Name:
Other - Last Name:ISSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1600 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3065
Mailing Address - Country:US
Mailing Address - Phone:863-680-7000
Mailing Address - Fax:866-264-8519
Practice Address - Street 1:1033 N PARKWAY FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-0401
Practice Address - Country:US
Practice Address - Phone:863-680-7000
Practice Address - Fax:866-264-8519
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME111615207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110095071AMedicaid
MA001551602Medicare PIN