Provider Demographics
NPI:1184672024
Name:DIVINE, RONALD W (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:W
Last Name:DIVINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2156
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-2156
Mailing Address - Country:US
Mailing Address - Phone:541-758-5047
Mailing Address - Fax:541-758-3713
Practice Address - Street 1:3501 N SCOTTSDALE RD STE 130
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-5649
Practice Address - Country:US
Practice Address - Phone:480-425-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR215362085R0202X
AZ367192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR138138Medicaid
AZ102232Medicaid
ORR132659Medicare PIN