Healthcare Provider Details

I. General information

NPI: 1558346825
Provider Name (Legal Business Name): RONALD JOSEPH IANNACONE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 11/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 HIGHWAY 70 BLDG 6B
MANASQUAN NJ
08736
US

IV. Provider business mailing address

2640 HIGHWAY 70 BLDG 6B
MANASQUAN NJ
08736-2609
US

V. Phone/Fax

Practice location:
  • Phone: 732-223-8686
  • Fax: 732-223-6572
Mailing address:
  • Phone: 732-223-8686
  • Fax: 732-223-6572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberMB55529
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: