Provider Demographics
NPI:1689670119
Name:IACOCCA, MARY VIRGINIA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:VIRGINIA
Last Name:IACOCCA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 12210
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19850-2210
Mailing Address - Country:US
Mailing Address - Phone:302-454-9830
Mailing Address - Fax:302-454-1445
Practice Address - Street 1:4755 OGLETOWN STANTON RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-6001
Practice Address - Country:US
Practice Address - Phone:302-454-9830
Practice Address - Fax:302-454-1445
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10006014207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEG16621Medicare UPIN