Provider Demographics
NPI:1245455666
Name:IANNICCA, DAVID (ATC)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:IANNICCA
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 CENTER RD
Mailing Address - Street 2:
Mailing Address - City:EASTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44095-2332
Mailing Address - Country:US
Mailing Address - Phone:440-223-0569
Mailing Address - Fax:
Practice Address - Street 1:15946 N BULLARD AVE
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-8844
Practice Address - Country:US
Practice Address - Phone:816-277-2954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260007562081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine