Healthcare Provider Details

I. General information

NPI: 1417691361
Provider Name (Legal Business Name): DIVINO D'ALESSIO JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 S FEDERAL HWY
BOCA RATON FL
33432-7413
US

IV. Provider business mailing address

300 SINGLETON RIDGE RD
CONWAY SC
29526-9142
US

V. Phone/Fax

Practice location:
  • Phone: 561-933-3333
  • Fax:
Mailing address:
  • Phone: 843-347-8134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME181970
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: