Provider Demographics
NPI:1467450833
Name:DIVENCENZO, ROBERT F (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:F
Last Name:DIVENCENZO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:908 NIAGARA FALLS BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:N TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-2019
Mailing Address - Country:US
Mailing Address - Phone:716-692-3302
Mailing Address - Fax:716-692-4342
Practice Address - Street 1:5300 MILITARY RD
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-1903
Practice Address - Country:US
Practice Address - Phone:716-298-3782
Practice Address - Fax:716-692-4342
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188929-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB5324Medicare PIN
NYF29101Medicare UPIN
NYCC9167Medicare PIN