Provider Demographics
NPI:1114916632
Name:DIVITO, MICHELLE C (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:C
Last Name:DIVITO
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 1:2813 27TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20008-4129
Mailing Address - Country:US
Mailing Address - Phone:202-270-6250
Mailing Address - Fax:301-921-7915
Practice Address - Street 1:1701 N GEORGE MASON DR
Practice Address - Street 2:VIRGINIA HOSPITAL CENTER
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3610
Practice Address - Country:US
Practice Address - Phone:703-558-6167
Practice Address - Fax:703-558-5355
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101237831207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010171067Medicaid
VA017574E14Medicare ID - Type Unspecified
I37135Medicare UPIN