Provider Demographics
NPI:1649295866
Name:IACOBELLI, CHRISTOPHER J (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:J
Last Name:IACOBELLI
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 1:66 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:POMEROY
Mailing Address - State:WA
Mailing Address - Zip Code:99347-9705
Mailing Address - Country:US
Mailing Address - Phone:509-843-1591
Mailing Address - Fax:509-843-1234
Practice Address - Street 1:825 SE BISHOP BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5537
Practice Address - Country:US
Practice Address - Phone:509-332-2517
Practice Address - Fax:509-334-9247
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-12956207Q00000X
MI4301074411207Q00000X
WAMD60568380207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0802506201OtherBCBSM INDIVIDUAL PIN
MI4775269Medicaid
MI4775269Medicaid
MIP20150001Medicare PIN