Provider Demographics
NPI:1275570673
Name:MCINTOSH-VICK, OVETA B (MD)
Entity Type:Individual
Prefix:
First Name:OVETA
Middle Name:B
Last Name:MCINTOSH-VICK
Suffix:
Gender:F
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:PO BOX 52119
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27717-2119
Mailing Address - Country:US
Mailing Address - Phone:919-956-4003
Mailing Address - Fax:919-956-4535
Practice Address - Street 1:1301 FAYETTEVILLE ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2325
Practice Address - Country:US
Practice Address - Phone:919-956-4000
Practice Address - Fax:919-956-4535
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29708208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8956802Medicaid
NC56802OtherNC BC/BS ID NO
NC56802OtherNC BC/BS ID NO
NCF09045Medicare UPIN