Provider Demographics
NPI:1649414293
Name:DIVIN, CECILIA ROMO (MD)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:ROMO
Last Name:DIVIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CECILIA
Other - Middle Name:
Other - Last Name:ROMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:PHYSICIAN SUPPORT SERVICES
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 PRAIRIE CITY RD
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-9594
Practice Address - Country:US
Practice Address - Phone:916-351-4800
Practice Address - Fax:916-351-4899
Is Sole Proprietor?:No
Enumeration Date:2009-04-27
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA113360207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEFFECTIVE 11/15/2013Medicaid