Provider Demographics
NPI:1205821303
Name:DIVITA, DAVID P (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:P
Last Name:DIVITA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5130 SUNFOREST DR STE 300
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-6327
Mailing Address - Country:US
Mailing Address - Phone:727-824-0780
Mailing Address - Fax:
Practice Address - Street 1:1120 10TH ST E
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-4134
Practice Address - Country:US
Practice Address - Phone:941-847-7903
Practice Address - Fax:941-847-7919
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86246207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267953100Medicaid
FL080194322OtherRAIL ROAD MEDICARE
FL57812OtherBCBS
FL267953100Medicaid
FL080194322OtherRAIL ROAD MEDICARE
FL57812ZMedicare PIN
FL57812OtherBCBS