Healthcare Provider Details

I. General information

NPI: 1811280894
Provider Name (Legal Business Name): CAESAR S. DIVINO D.P.M. PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2011
Last Update Date: 05/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3065 HIGHWAY 367 S SUITE 11
CABOT AR
72023-8660
US

IV. Provider business mailing address

3065 HIGHWAY 367 S SUITE 11
CABOT AR
72023-8660
US

V. Phone/Fax

Practice location:
  • Phone: 501-941-3797
  • Fax: 501-941-7760
Mailing address:
  • Phone: 501-941-3797
  • Fax: 501-941-7760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number164
License Number StateAR

VIII. Authorized Official

Name: MR. HECTOR SOLOMON DIVINO
Title or Position: OFFICE MANAGER
Credential:
Phone: 501-941-3797