Healthcare Provider Details

I. General information

NPI: 1588680110
Provider Name (Legal Business Name): DIVAGNO INTERVENTIONAL CARDIOLOGY MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 11/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 STATE RT 17 N SUITE 310
ROCHELLE PARK NJ
07662-3399
US

IV. Provider business mailing address

218 STATE RT 17 N SUITE 310
ROCHELLE PARK NJ
07662-3399
US

V. Phone/Fax

Practice location:
  • Phone: 201-845-3535
  • Fax: 201-845-4040
Mailing address:
  • Phone: 201-845-3535
  • Fax: 201-845-4040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMA69173
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: LEONARDO JOSEPH DIVAGNO
Title or Position: PRACTITIONER
Credential: MD
Phone: 201-845-3535