Provider Demographics
NPI:1295715324
Name:IACOBUCCI, MARK JOHN (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:IACOBUCCI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4445 LAKE FOREST DR
Mailing Address - Street 2:STE 600
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-3744
Mailing Address - Country:US
Mailing Address - Phone:513-569-3741
Mailing Address - Fax:513-569-3941
Practice Address - Street 1:3235 ACADEMY AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703
Practice Address - Country:US
Practice Address - Phone:757-483-0400
Practice Address - Fax:757-548-9563
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2021-06-04
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Provider Licenses
StateLicense IDTaxonomies
VA0101056490207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1295715324Medicaid
294885OtherANTHEM
VAP00381529Medicare PIN
H17210Medicare UPIN
VA1295715324Medicaid