Provider Demographics
NPI:1750463170
Name:MCDIVITT, JONATHAN DENLEA (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DENLEA
Last Name:MCDIVITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JONATHAN
Other - Middle Name:D
Other - Last Name:MCDIVITT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1240 INDIA ST UNIT 802
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-8532
Mailing Address - Country:US
Mailing Address - Phone:301-305-1901
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2111
Practice Address - Country:US
Practice Address - Phone:757-953-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101242092207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program