Healthcare Provider Details

I. General information

NPI: 1659370435
Provider Name (Legal Business Name): VICTOR R IANNACCONE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 JUPITER LAKES BLVD STE 200
JUPITER FL
33458-7100
US

IV. Provider business mailing address

770 NORTHPOINT PARKWAY SUITE 102
WEST PALM BEACH FL
33407
US

V. Phone/Fax

Practice location:
  • Phone: 561-741-1957
  • Fax: 561-741-1893
Mailing address:
  • Phone: 561-275-7604
  • Fax: 561-802-5385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberME63455
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: