=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225076235
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EUMENA DIVINO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2006
-----------------------------------------------------
Last Update Date | 04/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 390 NEW BRUNSWICK AVE
-----------------------------------------------------
City | FORDS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08863-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-738-4260
-----------------------------------------------------
Fax | 732-738-5693
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 48270
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07101-4800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-818-9118
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 25MA02674500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------