Provider Demographics
NPI:1659391761
Name:DIVINE, JON G (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:G
Last Name:DIVINE
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:222 PIEDMONT AVE
Mailing Address - Street 2:ML 0212
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-4231
Mailing Address - Country:US
Mailing Address - Phone:513-475-8690
Mailing Address - Fax:513-475-7593
Practice Address - Street 1:222 PIEDMONT AVE
Practice Address - Street 2:ML 0212
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-4231
Practice Address - Country:US
Practice Address - Phone:513-475-8690
Practice Address - Fax:513-475-7593
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-10-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH35-070497207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64077175Medicaid
OH2475503Medicaid
OHDE4298641Medicare PIN