=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083292288
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DINA ANN IACONE DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2021
-----------------------------------------------------
Last Update Date | 06/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3565 PHILADELPHIA PIKE
-----------------------------------------------------
City | CLAYMONT
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19703-3106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-320-4110
-----------------------------------------------------
Fax | 302-798-6672
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3565 PHILADELPHIA PIKE
-----------------------------------------------------
City | CLAYMONT
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19703-3106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-320-4110
-----------------------------------------------------
Fax | 302-798-6672
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | C2-0024450
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------