Basic Information
| Provider Information | |||||||||
| NPI: | 1184672024 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIVINE | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2156 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973392156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417585047 | ||||||||
| FaxNumber: | 5417583713 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 N SCOTTSDALE RD STE 130 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852515649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804255000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 02/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 21536 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 36719 | AZ | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 138138 | 05 | OR | MEDICAID | 102232 | 05 | AZ | MEDICAID |