Healthcare Provider Details

I. General information

NPI: 1083859649
Provider Name (Legal Business Name): THOMAS V DIVINAGRACIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2008
Last Update Date: 03/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SEYMOUR ST. SUITE 409
HARTFORD CT
06106
US

IV. Provider business mailing address

85 SEYMOUR ST. SUITE 409
HARTFORD CT
06106
US

V. Phone/Fax

Practice location:
  • Phone: 860-522-4158
  • Fax: 860-524-2652
Mailing address:
  • Phone: 860-522-4158
  • Fax: 860-524-2652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number046129
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number046129
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number046129
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: