Provider Demographics
NPI:1972562429
Name:DIVITO, STEPHEN TYLER (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:TYLER
Last Name:DIVITO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:572 TITUS AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-3519
Mailing Address - Country:US
Mailing Address - Phone:585-544-4077
Mailing Address - Fax:585-544-4070
Practice Address - Street 1:572 TITUS AVE
Practice Address - Street 2:SUITE C
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14617-3519
Practice Address - Country:US
Practice Address - Phone:585-544-4077
Practice Address - Fax:585-544-4070
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009211111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY16-1562329OtherTAX ID NO
NY16-1562329OtherTAX ID NO