Healthcare Provider Details

I. General information

NPI: 1902800329
Provider Name (Legal Business Name): VITTORIO PAOLO ANTONACCI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 12/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E MOREHEAD ST STE 300
CHARLOTTE NC
28202-2788
US

IV. Provider business mailing address

700 E MOREHEAD ST STE 300
CHARLOTTE NC
28202-2788
US

V. Phone/Fax

Practice location:
  • Phone: 704-334-7800
  • Fax: 704-414-7512
Mailing address:
  • Phone: 704-334-7800
  • Fax: 704-414-7512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number22750
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number00504
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number00504
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number22750
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: