Provider Demographics
NPI:1760641070
Name:LISA A IACOFANO MD PC
Entity Type:Organization
Organization Name:LISA A IACOFANO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:IACOFANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-665-0900
Mailing Address - Street 1:PO BOX 21150
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80308-4150
Mailing Address - Country:US
Mailing Address - Phone:303-665-0900
Mailing Address - Fax:303-926-1986
Practice Address - Street 1:335 W SOUTH BOULDER RD
Practice Address - Street 2:SUITE 6
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-1196
Practice Address - Country:US
Practice Address - Phone:303-665-0900
Practice Address - Fax:303-926-1986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31267207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01312677Medicaid
COCOB4126Medicare PIN
CO01312677Medicaid