Provider Demographics
NPI:1447286430
Name:DIVITO, JOHN (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DIVITO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3434 HANCOCK BRIDGE PKWY
Mailing Address - Street 2:STE 301
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-7094
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2625
Practice Address - Street 1:3530 FRUITVILLE RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34237-9026
Practice Address - Country:US
Practice Address - Phone:941-552-8808
Practice Address - Fax:941-552-8805
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2016-02-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9101034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292127800Medicaid
FLR80483Medicare UPIN