Healthcare Provider Details

I. General information

NPI: 1649344573
Provider Name (Legal Business Name): FRANK ANTHONY DIVINCENZO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 01/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 TRIMBLE RD STE 107
COLUMBIA MO
65201-7180
US

IV. Provider business mailing address

5227 E HIGHWAY 163
COLUMBIA MO
65201-9567
US

V. Phone/Fax

Practice location:
  • Phone: 573-818-3067
  • Fax:
Mailing address:
  • Phone: 573-268-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number102906
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: