Provider Demographics
NPI:1386697852
Name:IANNOTTI, MARK ROBERT
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
Last Name:IANNOTTI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 N HURSTBOURNE PKWY
Mailing Address - Street 2:STE 200
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5158
Mailing Address - Country:US
Mailing Address - Phone:941-486-5444
Mailing Address - Fax:941-486-5489
Practice Address - Street 1:930 TAMIAMI TRL S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-3653
Practice Address - Country:US
Practice Address - Phone:941-486-5444
Practice Address - Fax:941-486-5489
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 217692251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY911KOtherBC/BS
FLY911KOtherBC/BS