Provider Demographics
NPI:1588617856
Name:IACOB, MIRCEA TUDOR (MD)
Entity Type:Individual
Prefix:
First Name:MIRCEA
Middle Name:TUDOR
Last Name:IACOB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-933-4056
Mailing Address - Fax:630-933-4057
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1295
Practice Address - Country:US
Practice Address - Phone:630-933-4056
Practice Address - Fax:630-933-4057
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-113093174400000X
IL0361130932084N0400X, 2084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No174400000XOther Service ProvidersSpecialist
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1635130OtherBCBS
ILP01090248OtherRAILROAD MEDICARE PTAN (INDIVIDUAL)
IL206147084OtherMEDICARE PTAN (INDIVIDUAL)
IL036113093Medicaid
ILCE8792OtherRAILROAD MEDICARE PTAN (GROUP)
ILCE8792OtherRAILROAD MEDICARE PTAN (GROUP)
IL036113093Medicaid