Provider Demographics
NPI:1841783438
Name:MCDIVITT, DYLAN JAMES (DO)
Entity Type:Individual
Prefix:DR
First Name:DYLAN
Middle Name:JAMES
Last Name:MCDIVITT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:786 CARTERET CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-3205
Mailing Address - Country:US
Mailing Address - Phone:856-641-8000
Mailing Address - Fax:
Practice Address - Street 1:800 WALNUT ST FL 16
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5176
Practice Address - Country:US
Practice Address - Phone:215-829-0101
Practice Address - Fax:215-454-3625
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-08
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOS021351207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program