Basic Information
| Provider Information | |||||||||
| NPI: | 1467450833 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIVENCENZO | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 NIAGARA FALLS BLVD | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | N TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141202019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Practice Location | |||||||||
| Address1: | 5300 MILITARY RD | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140921903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162983782 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2005 | ||||||||
| LastUpdateDate: | 11/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 188929-1 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.