Healthcare Provider Details

I. General information

NPI: 1225161102
Provider Name (Legal Business Name): MICHAEL VINCENT DIVITO RPAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 LONG POND RD
ROCHESTER NY
14626-4164
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 585-723-7000
  • Fax: 585-723-7280
Mailing address:
  • Phone: 585-922-5462
  • Fax: 585-922-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number005032
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: