Healthcare Provider Details

I. General information

NPI: 1932916988
Provider Name (Legal Business Name): MR. JONATHAN DANIEL DIVEGLIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2024
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6439 GARNERS FERRY RD
COLUMBIA SC
29209-1638
US

IV. Provider business mailing address

238 HIGH POINTE DR
BLYTHEWOOD SC
29016-7608
US

V. Phone/Fax

Practice location:
  • Phone: 803-776-4000
  • Fax: 803-695-6877
Mailing address:
  • Phone: 603-312-5181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number532208
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: