Healthcare Provider Details

I. General information

NPI: 1053719807
Provider Name (Legal Business Name): VANTAGE CANCER CARE - PENNSYLVANIA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2014
Last Update Date: 12/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 JOHN YOUNG WAY SUITE 400
EXTON PA
19341-2557
US

IV. Provider business mailing address

1500 ROSECRANS AVE SUITE 400
MANHATTAN BEACH CA
90266-3763
US

V. Phone/Fax

Practice location:
  • Phone: 610-524-5550
  • Fax:
Mailing address:
  • Phone: 310-335-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN IACUONE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 505-220-9973