Provider Demographics
NPI:1679981229
Name:CITLA SRIDHAR, DIVYASWATHI (MD)
Entity type:Individual
Prefix:
First Name:DIVYASWATHI
Middle Name:
Last Name:CITLA SRIDHAR
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 1:1 CHILDRENS WAY # 653
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3500
Mailing Address - Country:US
Mailing Address - Phone:501-364-1100
Mailing Address - Fax:501-364-4082
Practice Address - Street 1:1 CHILDRENS WAY # 512-10
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3500
Practice Address - Country:US
Practice Address - Phone:501-364-2270
Practice Address - Fax:501-364-2295
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-12928208000000X, 2080P0207X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology