Healthcare Provider Details

I. General information

NPI: 1164404976
Provider Name (Legal Business Name): MARK DAVID IANNETTONI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 HEART DR
GREENVILLE NC
27834-8982
US

IV. Provider business mailing address

PO BOX 751069 ECU PHYSICIANS
CHARLOTTE NC
28275-1069
US

V. Phone/Fax

Practice location:
  • Phone: 252-744-4400
  • Fax: 252-744-3987
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number35447
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2014-01742
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: