Provider Demographics
NPI:1134237092
Name:CANCELLARO, VITO ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:VITO
Middle Name:ANTHONY
Last Name:CANCELLARO
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 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6308
Mailing Address - Fax:
Practice Address - Street 1:67 CREEKSIDE PARK CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4810
Practice Address - Country:US
Practice Address - Phone:864-242-4602
Practice Address - Fax:864-242-0129
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26314207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC263146Medicaid
SCSC4750E178Medicare PIN
SCAA0880Medicare ID - Type Unspecified