Healthcare Provider Details

I. General information

NPI: 1841783438
Provider Name (Legal Business Name): DYLAN JAMES MCDIVITT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 EAST AVE STE C
WOODSTOWN NJ
08098-1351
US

IV. Provider business mailing address

786 CARTERET CT
MOUNT LAUREL NJ
08054-3205
US

V. Phone/Fax

Practice location:
  • Phone: 856-769-2800
  • Fax: 856-769-4256
Mailing address:
  • Phone: 856-641-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB10990100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: