Basic Information
Provider Information | |||||||||
NPI: | 1669553608 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCDIVITT | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 16107 KENSINGTON DR STE 126 | ||||||||
Address2: |   | ||||||||
City: | SUGAR LAND | ||||||||
State: | TX | ||||||||
PostalCode: | 774794224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2817838162 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10705 SPRING GREEN BLVD, STE. 200 | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770961605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2817838162 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/18/2006 | ||||||||
LastUpdateDate: | 11/06/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP111300 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 8N7490 | 01 | TX | BLUE CROSS & BLUE SHIELD | OTHER |