Provider Demographics
NPI:1063500783
Name:INCATASCIATO, RUSSELL ANTHONY (DO)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ANTHONY
Last Name:INCATASCIATO
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 1:4402 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6161
Mailing Address - Country:US
Mailing Address - Phone:910-452-1400
Mailing Address - Fax:910-791-9626
Practice Address - Street 1:4402 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6161
Practice Address - Country:US
Practice Address - Phone:910-452-1400
Practice Address - Fax:910-791-9626
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900882207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891199VMedicaid
SCQ09872Medicaid
NCP00374412OtherRAILROAD MEDICARE
NC1199VOtherBCBS
NC2059145AMedicare PIN
NC2059145Medicare PIN
NC891199VMedicaid