Provider Demographics
NPI:1588680110
Name:DIVAGNO INTERVENTIONAL CARDIOLOGY MD PA
Entity Type:Organization
Organization Name:DIVAGNO INTERVENTIONAL CARDIOLOGY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LEONARDO
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DIVAGNO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-845-3535
Mailing Address - Street 1:218 STATE RT 17 N
Mailing Address - Street 2:SUITE 310
Mailing Address - City:ROCHELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07662-3399
Mailing Address - Country:US
Mailing Address - Phone:201-845-3535
Mailing Address - Fax:201-845-4040
Practice Address - Street 1:218 STATE RT 17 N
Practice Address - Street 2:SUITE 310
Practice Address - City:ROCHELLE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07662-3399
Practice Address - Country:US
Practice Address - Phone:201-845-3535
Practice Address - Fax:201-845-4040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA69173207RC0000X
207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8750009Medicaid
P2656071OtherOXFORD
G23362Medicare UPIN
P2656071OtherOXFORD
NJ087792Medicare PIN