Provider Demographics
NPI:1407142425
Name:MICHAEL C. IANNIELLO, DO
Entity Type:Organization
Organization Name:MICHAEL C. IANNIELLO, DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:IANNIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-235-3752
Mailing Address - Street 1:2560 JUDGE FRAN JAMIESON WAY UNIT 1313
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-6199
Mailing Address - Country:US
Mailing Address - Phone:954-235-3752
Mailing Address - Fax:
Practice Address - Street 1:2560 JUDGE FRAN JAMIESON WAY UNIT 1313
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940
Practice Address - Country:US
Practice Address - Phone:954-235-3752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-28
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
FLME97967207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279400400Medicaid
FL279400400Medicaid
FLDR540AMedicare PIN