Basic Information
| Provider Information | |||||||||
| NPI: | 1568453223 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIVGI | ||||||||
| FirstName: | AJIT | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 PLEASANT VALLEY RD | ||||||||
| Address2: | KRAEMER CANCER CARE CENTER | ||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530959274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628367200 | ||||||||
| FaxNumber: | 2623348484 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 PLEASANT VALLEY RD | ||||||||
| Address2: | KRAEMER CANCER CARE CENTER | ||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530959274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628367200 | ||||||||
| FaxNumber: | 2623348484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 09/10/2014 | ||||||||
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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 | 207RH0003X | 21657 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1568453223 | 05 | WI | MEDICAID |