Provider Demographics
NPI:1558346825
Name:IANNACONE, RONALD JOSEPH (DO)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:JOSEPH
Last Name:IANNACONE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 HIGHWAY 70
Mailing Address - Street 2:BLDG 6B
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736-2609
Mailing Address - Country:US
Mailing Address - Phone:732-223-8686
Mailing Address - Fax:732-223-6572
Practice Address - Street 1:2640 HIGHWAY 70
Practice Address - Street 2:BLDG 6B
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736
Practice Address - Country:US
Practice Address - Phone:732-223-8686
Practice Address - Fax:732-223-6572
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB55529207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6217401Medicaid
NJIA472218Medicare ID - Type Unspecified
NJ6217401Medicaid