Provider Demographics
NPI:1912973710
Name:DIVINO, CELIA (MD)
Entity Type:Individual
Prefix:
First Name:CELIA
Middle Name:
Last Name:DIVINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUSTAVE L LEVY PL.
Mailing Address - Street 2:BOX 1263
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6574
Mailing Address - Country:US
Mailing Address - Phone:212-241-3348
Mailing Address - Fax:212-534-2654
Practice Address - Street 1:5 EAST 98TH STREET
Practice Address - Street 2:14TH FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6574
Practice Address - Country:US
Practice Address - Phone:212-241-3348
Practice Address - Fax:212-534-2654
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193856208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01777435Medicaid
NY01777435Medicaid
NY68L651Medicare ID - Type Unspecified