Provider Demographics
NPI:1992783872
Name:IACOBELLI, DAVIDE (MD)
Entity type:Individual
Prefix:DR
First Name:DAVIDE
Middle Name:
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 1:16510 19 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038
Mailing Address - Country:US
Mailing Address - Phone:586-263-7200
Mailing Address - Fax:586-286-8007
Practice Address - Street 1:16510 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038
Practice Address - Country:US
Practice Address - Phone:586-263-7200
Practice Address - Fax:586-286-8007
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301045230207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1044574Medicaid
MI1044574Medicaid
A79947Medicare UPIN