Basic Information
| Provider Information | |||||||||
| NPI: | 1205001823 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAPPANAD | ||||||||
| FirstName: | DIVYA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 SE 164TH AVE | ||||||||
| Address2: | DEPT. 358 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986839324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607291462 | ||||||||
| FaxNumber: | 3607293104 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 DELAWARE ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986322367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604142730 | ||||||||
| FaxNumber: | 3604142739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2008 | ||||||||
| LastUpdateDate: | 11/11/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 141454 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | MD60329899 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207R00000X | MD60329899 | WA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | MD60329899 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 2027977 | 05 | WA | MEDICAID |