Provider Demographics
NPI:1497150742
Name:IACOBUCCI, MARK D (P T)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:IACOBUCCI
Suffix:
Gender:M
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5487 STAG THICKET LN
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-2525
Mailing Address - Country:US
Mailing Address - Phone:727-417-6334
Mailing Address - Fax:
Practice Address - Street 1:5487 STAG THICKET LN
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34685-2525
Practice Address - Country:US
Practice Address - Phone:727-417-6334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT85722251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic