Provider Demographics
NPI:1215936356
Name:PALAGRUTO, DOMENIC A (DO)
Entity type:Individual
Prefix:
First Name:DOMENIC
Middle Name:A
Last Name:PALAGRUTO
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 1:3599 GEORGE II HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-9766
Mailing Address - Country:US
Mailing Address - Phone:910-845-3244
Mailing Address - Fax:910-845-3276
Practice Address - Street 1:3599 GEORGE II HWY
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-7793
Practice Address - Country:US
Practice Address - Phone:910-845-3244
Practice Address - Fax:910-845-3276
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8913270Medicaid
NC13270OtherBC/BS NUMBER
NC8913270Medicaid
NC13270OtherBC/BS NUMBER