Provider Demographics
NPI:1508891011
Name:IACOFANO, LISA A (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:IACOFANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 SOUTH BOULDER ROAD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027
Mailing Address - Country:US
Mailing Address - Phone:303-665-0900
Mailing Address - Fax:303-926-1986
Practice Address - Street 1:335 SOUTH BOULDER ROAD
Practice Address - Street 2:SUITE 6
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027
Practice Address - Country:US
Practice Address - Phone:303-665-0900
Practice Address - Fax:303-926-1986
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31267207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01312677Medicaid
COCO40140Medicare PIN
CO01312677Medicaid