Provider Demographics
NPI:1851392435
Name:DIVAGNO, LEONARDO JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONARDO
Middle Name:JOSEPH
Last Name:DIVAGNO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 ROUTE 17 NORTH STE 201
Mailing Address - Street 2:
Mailing Address - City:ROCHELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07662-3333
Mailing Address - Country:US
Mailing Address - Phone:201-845-3535
Mailing Address - Fax:201-845-4040
Practice Address - Street 1:216 ROUTE 17 NORTH STE 201
Practice Address - Street 2:
Practice Address - City:ROCHELLE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07662
Practice Address - Country:US
Practice Address - Phone:201-845-3535
Practice Address - Fax:201-845-4040
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA69173207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
2917787OtherGHI
NJ8750009Medicaid
P2656071OtherOXFORD
P2656071OtherOXFORD
G23362Medicare UPIN
NJ8750009Medicaid