Provider Demographics
NPI:1548559123
Name:IACCARINO, MARY ALEXIS (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALEXIS
Last Name:IACCARINO
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 1:125 NASHUA ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-1101
Mailing Address - Country:US
Mailing Address - Phone:617-573-7000
Mailing Address - Fax:
Practice Address - Street 1:1215 LEE ST
Practice Address - Street 2:BOX 800793
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0816
Practice Address - Country:US
Practice Address - Phone:434-924-5118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA251264208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program