Provider Demographics
NPI:1235499427
Name:IACOVINO, JOHN RALPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RALPH
Last Name:IACOVINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 LEGACY WOODS DR
Mailing Address - Street 2:
Mailing Address - City:WALLACE
Mailing Address - State:NC
Mailing Address - Zip Code:28466-2398
Mailing Address - Country:US
Mailing Address - Phone:910-285-5342
Mailing Address - Fax:
Practice Address - Street 1:149 LEGACY WOODS DR
Practice Address - Street 2:
Practice Address - City:WALLACE
Practice Address - State:NC
Practice Address - Zip Code:28466-2398
Practice Address - Country:US
Practice Address - Phone:910-285-5342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC119396174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist