Basic Information
| Provider Information | |||||||||
| NPI: | 1508861642 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIVINCENTI | ||||||||
| FirstName: | FRANK | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 MEDICAL CENTER BLVD | ||||||||
| Address2: | STE 713N | ||||||||
| City: | MARRERO | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700723151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043496713 | ||||||||
| FaxNumber: | 5043496733 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 MEDICAL CENTER BLVD | ||||||||
| Address2: | STE 713N | ||||||||
| City: | MARRERO | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700723151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043496713 | ||||||||
| FaxNumber: | 5043496733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 009228 | LA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1107514 | 05 | LA | MEDICAID |