Provider Demographics
NPI:1598744757
Name:DIVITA, PENNY S (DO)
Entity Type:Individual
Prefix:
First Name:PENNY
Middle Name:S
Last Name:DIVITA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 PENNSYLVANIA AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-3302
Mailing Address - Country:US
Mailing Address - Phone:304-388-2709
Mailing Address - Fax:
Practice Address - Street 1:830 PENNSYLVANIA AVE
Practice Address - Street 2:STE 200
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3302
Practice Address - Country:US
Practice Address - Phone:304-388-2709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1461207P00000X
WV1451208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001718046OtherBLUE CROSS BLUE SHIELD
WV0046618000Medicaid
WV1040493OtherDWC
WV001718046OtherBLUE CROSS BLUE SHIELD
WVG15685Medicare UPIN
WV0046618000Medicaid