Provider Demographics
NPI:1194258277
Name:DIVELLA, MICHAEL (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:DIVELLA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 MCCOMBS RD
Mailing Address - Street 2:
Mailing Address - City:VENETIA
Mailing Address - State:PA
Mailing Address - Zip Code:15367-1385
Mailing Address - Country:US
Mailing Address - Phone:724-986-7844
Mailing Address - Fax:
Practice Address - Street 1:2201 HEMPSTEAD TURNPIKE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554
Practice Address - Country:US
Practice Address - Phone:516-296-2388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program