Basic Information
| Provider Information | |||||||||
| NPI: | 1295795458 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IANNACONE | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 W MAIN ST | ||||||||
| Address2: | SUITE 16 | ||||||||
| City: | WYCKOFF | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074811439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018479403 | ||||||||
| FaxNumber: | 2018470059 | ||||||||
| Practice Location | |||||||||
| Address1: | VALLEY HOSPITAL | ||||||||
| Address2: | 233 VAN DIEN AVE | ||||||||
| City: | RIDGEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014478000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 25MB05568500 | NJ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 6067204 | 05 | NJ | MEDICAID |