Provider Demographics
NPI:1568453223
Name:DIVGI, AJIT B (MD)
Entity Type:Individual
Prefix:
First Name:AJIT
Middle Name:B
Last Name:DIVGI
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3200 PLEASANT VALLEY RD
Mailing Address - Street 2:KRAEMER CANCER CARE CENTER
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9274
Mailing Address - Country:US
Mailing Address - Phone:262-836-7200
Mailing Address - Fax:262-334-8484
Practice Address - Street 1:3200 PLEASANT VALLEY RD
Practice Address - Street 2:KRAEMER CANCER CARE CENTER
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9274
Practice Address - Country:US
Practice Address - Phone:262-836-7200
Practice Address - Fax:262-334-8484
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI21657207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1568453223Medicaid
WIK400127979Medicare PIN
WIK400127980Medicare PIN