Provider Demographics
NPI:1770118929
Name:DISIENO, MICHAEL JOSEPH (LCAS)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:DISIENO
Suffix:
Gender:M
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 N CULVERTON RD
Mailing Address - Street 2:
Mailing Address - City:WINNABOW
Mailing Address - State:NC
Mailing Address - Zip Code:28479-2103
Mailing Address - Country:US
Mailing Address - Phone:252-526-1252
Mailing Address - Fax:
Practice Address - Street 1:1230 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7332
Practice Address - Country:US
Practice Address - Phone:910-799-5452
Practice Address - Fax:910-799-5479
Is Sole Proprietor?:No
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-687207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine