Provider Demographics
NPI:1669553608
Name:MCDIVITT, JOHN A (NP)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:MCDIVITT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:16107 KENSINGTON DR STE 126
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-4224
Mailing Address - Country:US
Mailing Address - Phone:281-783-8162
Mailing Address - Fax:
Practice Address - Street 1:10705 SPRING GREEN BLVD, STE. 200
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77096-1605
Practice Address - Country:US
Practice Address - Phone:281-783-8162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP111300363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N7490OtherBLUE CROSS & BLUE SHIELD
TXP41972Medicare UPIN
TX8D5356Medicare PIN
TX8E0055Medicare PIN