Provider Demographics
NPI:1679101489
Name:DEGENOVA, DANIEL THOMAS
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:THOMAS
Last Name:DEGENOVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5131 BEACON HILL RD STE 160
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43228-4441
Mailing Address - Country:US
Mailing Address - Phone:614-544-1837
Mailing Address - Fax:
Practice Address - Street 1:5131 BEACON HILL RD STE 160
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-4441
Practice Address - Country:US
Practice Address - Phone:614-544-1837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-28
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ011419207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program