Provider Demographics
NPI:1497706162
Name:IACOBONI, STEPHEN J (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:J
Last Name:IACOBONI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21015
Mailing Address - Street 2:521 HAMMILL LN.
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89515
Mailing Address - Country:US
Mailing Address - Phone:775-827-0707
Mailing Address - Fax:775-827-1006
Practice Address - Street 1:3006 S MARYLAND PKWY STE 205
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109
Practice Address - Country:US
Practice Address - Phone:702-735-7154
Practice Address - Fax:702-735-7153
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8193207RX0202X
WAMD00024072207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1497706162Medicaid
NV15296OtherSTATE LICENSE
ID805994300Medicaid
WA1497706162Medicaid
WAG8892167Medicare PIN