Provider Demographics
NPI:1326021825
Name:DIVITTORIO, ALBERT JOSEPH JR (M D)
Entity Type:Individual
Prefix:DR
First Name:ALBERT
Middle Name:JOSEPH
Last Name:DIVITTORIO
Suffix:JR
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 FOWLER WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-5701
Mailing Address - Country:US
Mailing Address - Phone:530-626-3260
Mailing Address - Fax:530-626-8941
Practice Address - Street 1:1008 FOWLER WAY
Practice Address - Street 2:SUITE A
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-5701
Practice Address - Country:US
Practice Address - Phone:530-626-3260
Practice Address - Fax:530-626-8941
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC32238174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA34857Medicare UPIN
00C322380Medicare ID - Type Unspecified