Basic Information
| Provider Information | |||||||||
| NPI: | 1720265929 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOODALBAIL | ||||||||
| FirstName: | DIVYA | ||||||||
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| OtherLastName: | MOODALBAIL | ||||||||
| OtherFirstName: | DIVYA | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 710 LAWRENCE EXPY | ||||||||
| Address2: | |||||||||
| City: | SANTA CLARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950515173 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 710 LAWRENCE EXPY | ||||||||
| Address2: | |||||||||
| City: | SANTA CLARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950515173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4088511240 | ||||||||
| FaxNumber: | 4088511240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2008 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0210X | CA | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology |
No ID Information.