Provider Demographics
NPI:1083673784
Name:IACARUSO, MICHELLE L (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:L
Last Name:IACARUSO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 OLCOTT SQ
Mailing Address - Street 2:
Mailing Address - City:BERNARDSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07924-2317
Mailing Address - Country:US
Mailing Address - Phone:908-221-1919
Mailing Address - Fax:908-221-1005
Practice Address - Street 1:39 OLCOTT SQ
Practice Address - Street 2:
Practice Address - City:BERNARDSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07924-2317
Practice Address - Country:US
Practice Address - Phone:908-221-1919
Practice Address - Fax:908-221-1005
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08365400207Q00000X
PAOS009282L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA022757Medicare ID - Type Unspecified
G85381Medicare UPIN