Provider Demographics
NPI:1386608339
Name:DIVAN, NITA K (MD)
Entity type:Individual
Prefix:DR
First Name:NITA
Middle Name:K
Last Name:DIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1528
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14231-1528
Mailing Address - Country:US
Mailing Address - Phone:716-688-7344
Mailing Address - Fax:716-688-7345
Practice Address - Street 1:1150 YOUNGS RD
Practice Address - Street 2:SUITE 203
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8053
Practice Address - Country:US
Practice Address - Phone:716-688-7344
Practice Address - Fax:716-688-7345
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2009-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY200884207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01657107Medicaid
NYBA0766Medicare PIN
G69668Medicare UPIN