1366544843 NPI number — DARIUS JOSE AYALA DIVINA DO

Table of content: DARIUS JOSE AYALA DIVINA DO (NPI 1366544843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366544843 NPI number — DARIUS JOSE AYALA DIVINA DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIVINA
Provider First Name:
DARIUS
Provider Middle Name:
JOSE AYALA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366544843
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1501 N BICKETT BLVD STE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISBURG
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27549-2178
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-497-8380
Provider Business Mailing Address Fax Number:
919-497-8385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 N BICKETT BLVD STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISBURG
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27549-2178
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-497-8380
Provider Business Practice Location Address Fax Number:
919-497-8385
Provider Enumeration Date:
09/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  1135 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: 2018-02770 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3255 . This is a "MEDICARE PTAN FOR ABBEVILLE OFFICE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 011356 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1366544843 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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