1811280894 NPI number — CAESAR S. DIVINO D.P.M. PA

Table of content: (NPI 1811280894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811280894 NPI number — CAESAR S. DIVINO D.P.M. PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAESAR S. DIVINO D.P.M. PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811280894
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3065 HIGHWAY 367 S
Provider Second Line Business Mailing Address:
SUITE 11
Provider Business Mailing Address City Name:
CABOT
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72023-8660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-941-3797
Provider Business Mailing Address Fax Number:
501-941-7760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3065 HIGHWAY 367 S
Provider Second Line Business Practice Location Address:
SUITE 11
Provider Business Practice Location Address City Name:
CABOT
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72023-8660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-941-3797
Provider Business Practice Location Address Fax Number:
501-941-7760
Provider Enumeration Date:
05/24/2011

Additional Information

Authorized Official

Authorized Official Last Name:
DIVINO
Authorized Official First Name:
HECTOR
Authorized Official Middle Name:
SOLOMON
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
501-941-3797

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  164 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 145589748 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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