Provider Demographics
NPI:1376500686
Name:DIVINAGRACIA, THOMAS D (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
Last Name:DIVINAGRACIA
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 1:27 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:NORWELL
Mailing Address - State:MA
Mailing Address - Zip Code:02061-2226
Mailing Address - Country:US
Mailing Address - Phone:781-826-6872
Mailing Address - Fax:
Practice Address - Street 1:114 WHITWELL ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-1870
Practice Address - Country:US
Practice Address - Phone:617-328-4030
Practice Address - Fax:617-376-5683
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA33545208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0153621Medicaid
MA0153621Medicaid
MAA53879Medicare UPIN