Provider Demographics
NPI:1891929311
Name:DIVINO NINO PEDIATRICS
Entity Type:Organization
Organization Name:DIVINO NINO PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:NUNEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-590-0660
Mailing Address - Street 1:557 E FORDHAM RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-5001
Mailing Address - Country:US
Mailing Address - Phone:347-590-0660
Mailing Address - Fax:347-590-0663
Practice Address - Street 1:557 E FORDHAM RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5001
Practice Address - Country:US
Practice Address - Phone:347-590-0660
Practice Address - Fax:347-590-0663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-12
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2482392080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03031041Medicaid