Basic Information
| Provider Information | |||||||||
| NPI: | 1275570673 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCINTOSH-VICK | ||||||||
| FirstName: | OVETA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 52119 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277172119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199564003 | ||||||||
| FaxNumber: | 9199564535 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 FAYETTEVILLE ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277072325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199564000 | ||||||||
| FaxNumber: | 9199564535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 09/06/2011 | ||||||||
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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 | 208000000X | 29708 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 8956802 | 05 | NC | MEDICAID | 56802 | 01 | NC | NC BC/BS ID NO | OTHER |