Provider Demographics
NPI:1578668893
Name:IACCINO, DAVID G (DPM)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:G
Last Name:IACCINO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10661 S ROBERTS ROAD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-1992
Mailing Address - Country:US
Mailing Address - Phone:708-974-4380
Mailing Address - Fax:708-974-4383
Practice Address - Street 1:10661 S ROBERTS RD
Practice Address - Street 2:SUITE 108
Practice Address - City:PALOS HILLS
Practice Address - State:IL
Practice Address - Zip Code:60465-1992
Practice Address - Country:US
Practice Address - Phone:708-974-4380
Practice Address - Fax:708-974-4383
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003882213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
480006875OtherRAILROAD MCR
IL60001580OtherBLUE CROSS BLUE SHIELD
0517920001Medicare NSC
772790Medicare PIN
T38849Medicare UPIN