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General NPI Number Information
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NPI Number | 1932916988
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Entity Type | Individual
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Provider Name | MR. JONATHAN DANIEL DIVEGLIA
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Gender | Male
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Dates
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Enumeration Date | 12/13/2024
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Last Update Date | 12/13/2024
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Provider Practice Location Address
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Address Line | 6439 GARNERS FERRY RD
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City | COLUMBIA
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State | SC
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Zip | 29209-1638
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Country | US
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Telephone | 803-776-4000
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Fax | 803-695-6877
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Provider Business Mailing Address
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Address Line | 238 HIGH POINTE DR
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City | BLYTHEWOOD
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State | SC
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Zip | 29016-7608
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Country | US
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Telephone | 603-312-5181
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085B0100X
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Taxonomy Name | Body Imaging Physician
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License Number | 532208
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License Number State | SC
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