Provider Demographics
NPI:1316979982
Name:DIVILBISS, DANIEL DAVID (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:DAVID
Last Name:DIVILBISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-3869
Mailing Address - Country:US
Mailing Address - Phone:864-725-4865
Mailing Address - Fax:864-725-4883
Practice Address - Street 1:155 ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-3869
Practice Address - Country:US
Practice Address - Phone:864-725-4865
Practice Address - Fax:864-725-4883
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27947207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC279479Medicaid
SCAA26801124Medicare PIN
SCAA2680Medicare UPIN
SCAA26801127Medicare PIN