Provider Demographics
NPI:1770522823
Name:IACOVELLI, BENEDETTO A (MD)
Entity type:Individual
Prefix:DR
First Name:BENEDETTO
Middle Name:A
Last Name:IACOVELLI
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 1:3114 CROASDAILE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2508
Mailing Address - Country:US
Mailing Address - Phone:919-425-1565
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28792-5272
Practice Address - Country:US
Practice Address - Phone:877-751-1157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98-01310207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1207AOtherBCBS OF NC
P00010556OtherRAILROAD
NC891207AMedicaid
SCQ01313Medicaid
P00010556OtherRAILROAD
2275158CMedicare ID - Type Unspecified