Provider Demographics
NPI:1598758278
Name:IANNACONE, ROBERT A (DPM, PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:IANNACONE
Suffix:
Gender:M
Credentials:DPM, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:691 SW PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1998
Mailing Address - Country:US
Mailing Address - Phone:772-878-0040
Mailing Address - Fax:778-878-4265
Practice Address - Street 1:691 SW PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-1998
Practice Address - Country:US
Practice Address - Phone:772-878-0040
Practice Address - Fax:772-878-4265
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO0002344213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390134300Medicaid
6200153OtherGHI
1158590001OtherMEDICARE DME
5400043OtherAETNA
FL65302OtherBLUE CROSS BLUE SHIELD
1158590001OtherMEDICARE DME
FL65302Medicare ID - Type Unspecified