Provider Demographics
NPI:1811280894
Name:CAESAR S. DIVINO D.P.M. PA
Entity type:Organization
Organization Name:CAESAR S. DIVINO D.P.M. PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:HECTOR
Authorized Official - Middle Name:SOLOMON
Authorized Official - Last Name:DIVINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-941-3797
Mailing Address - Street 1:3065 HIGHWAY 367 S
Mailing Address - Street 2:SUITE 11
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-8660
Mailing Address - Country:US
Mailing Address - Phone:501-941-3797
Mailing Address - Fax:501-941-7760
Practice Address - Street 1:3065 HIGHWAY 367 S
Practice Address - Street 2:SUITE 11
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-8660
Practice Address - Country:US
Practice Address - Phone:501-941-3797
Practice Address - Fax:501-941-7760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR164213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145589748Medicaid
5T571Medicare PIN
AR145589748Medicaid
5023800001Medicare NSC