Basic Information
| Provider Information | |||||||||
| NPI: | 1114923620 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANTONACCI | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751069 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527443520 | ||||||||
| FaxNumber: | 2527443194 | ||||||||
| Practice Location | |||||||||
| Address1: | 905 JOHNS HOPKINS DR | ||||||||
| Address2: | ECU PHYSICIANS PSYCHIATRIC MEDICINE- OUTPATIENT CLINIC | ||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278347225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527441406 | ||||||||
| FaxNumber: | 2527442419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 10/26/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 27355 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 8911625 | 05 | NC | MEDICAID | 11625 | 01 | NC | BCBS NC | OTHER | 260032395 | 01 | NC | RAILROAD MEDICARE | OTHER |