Basic Information
| Provider Information | |||||||||
| NPI: | 1720020639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IAQUINTO | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 370 | ||||||||
| Address2: | |||||||||
| City: | FORTSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 318080370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 7064943008 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 MEDICAL PARK | ||||||||
| Address2: | STE. 330 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967305 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 06/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 2005010201 | MO | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0801X | 2005010201 | MO | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207XX0801X | 30693 | SC | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
ID Information
| ID | Type | State | Issuer | Description | 01-0838370 | 01 | MO | COVENTRY | OTHER | 207429408 | 05 | MO | MEDICAID | 35477015 | 01 | MO | BCBS(PHP) RMC LOCATION | OTHER | 56779 | 01 | MO | HEALTHCARE USA-MIDWEST LO | OTHER | 200326830A | 05 | KS | MEDICAID | 35477025 | 01 | MO | BCBS(PHP) MIDWEST TRAUMA | OTHER | 4403943 | 01 | MO | AETNA | OTHER | 76-0726650 | 01 | MO | HUMANA | OTHER | 200326830B | 05 | KS | MEDICAID | 306939 | 05 | SC | MEDICAID | 925760 | 01 | MO | FIRST GUARD-RMC LOCATION | OTHER |