Provider Demographics
NPI:1245247949
Name:JACONO, ANDREW ANGELO (MD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:ANGELO
Last Name:JACONO
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 1:440 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021
Mailing Address - Country:US
Mailing Address - Phone:516-773-4646
Mailing Address - Fax:516-773-1360
Practice Address - Street 1:440-450 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021
Practice Address - Country:US
Practice Address - Phone:516-773-4646
Practice Address - Fax:516-773-1360
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2089311207Y00000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H40156Medicare UPIN
AJ06M75910Medicare ID - Type Unspecified