Provider Demographics
NPI:1952368193
Name:DIVITO, CHERYL T (DO)
Entity Type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:T
Last Name:DIVITO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8815
Mailing Address - Fax:
Practice Address - Street 1:326 NICHOLS RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-1914
Practice Address - Country:US
Practice Address - Phone:978-343-5270
Practice Address - Fax:978-343-5390
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226448207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA221845OtherUGS
MAJ41019OtherBLUE SHIELD OF MA
MA1319833Medicaid
MAM21400Medicare Oscar/Certification
MAI49088Medicare UPIN
MAA39594Medicare PIN