Healthcare Provider Details

I. General information

NPI: 1215936356
Provider Name (Legal Business Name): DOMENIC A PALAGRUTO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3599 GEORGE II HWY
SOUTHPORT NC
28461-7793
US

IV. Provider business mailing address

3599 GEORGE II HWY
SOUTHPORT NC
28461-9766
US

V. Phone/Fax

Practice location:
  • Phone: 910-845-3244
  • Fax: 910-845-3276
Mailing address:
  • Phone: 910-845-3244
  • Fax: 910-845-3276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: