Provider Demographics
NPI: | 1013160043 |
---|---|
Name: | IACOVELLA, GINA MARIE (MD MS) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | GINA |
Middle Name: | MARIE |
Last Name: | IACOVELLA |
Suffix: | |
Gender: | F |
Credentials: | MD MS |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 3100 E FLETCHER AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | TAMPA |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33613-4613 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 407-303-7283 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3100 E FLETCHER AVE |
Practice Address - Street 2: | |
Practice Address - City: | TAMPA |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33613-4613 |
Practice Address - Country: | US |
Practice Address - Phone: | 407-303-7283 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2008-11-04 |
Last Update Date: | 2023-07-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | ME118987 | 207RN0300X, 207RC0200X |
MN | 56924 | 207RC0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RC0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
No | 207RN0300X | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IA | ENROLLED | Medicaid | |
MN | H400095276 | Medicare PIN | |
MN | ENROLLED | Medicaid |