Healthcare Provider Details

I. General information

NPI: 1184672024
Provider Name (Legal Business Name): RONALD W DIVINE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 02/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 N SCOTTSDALE RD STE 130
SCOTTSDALE AZ
85251-5649
US

IV. Provider business mailing address

PO BOX 2156
CORVALLIS OR
97339-2156
US

V. Phone/Fax

Practice location:
  • Phone: 480-425-5000
  • Fax:
Mailing address:
  • Phone: 541-758-5047
  • Fax: 541-758-3713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number21536
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number36719
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: