Provider Demographics
NPI:1366544843
Name:DIVINA, DARIUS JOSE AYALA (DO)
Entity type:Individual
Prefix:
First Name:DARIUS
Middle Name:JOSE AYALA
Last Name:DIVINA
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 1:1501 N BICKETT BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:LOUISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27549-2178
Mailing Address - Country:US
Mailing Address - Phone:919-497-8380
Mailing Address - Fax:919-497-8385
Practice Address - Street 1:1501 N BICKETT BLVD STE E
Practice Address - Street 2:
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549-2178
Practice Address - Country:US
Practice Address - Phone:919-497-8380
Practice Address - Fax:919-497-8385
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1135207X00000X
NC2018-02770207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3255OtherMEDICARE PTAN FOR ABBEVILLE OFFICE
SC011356Medicaid
NC1366544843Medicaid
SC3255OtherMEDICARE PTAN FOR ABBEVILLE OFFICE