Individual
MARK JOHN IACOBUCCI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
3235 ACADEMY AVE, SUITE 200, PORTSMOUTH, VA 23703
(757) 483-0400
(757) 548-9563
Mailing address
4445 LAKE FOREST DR, STE 600, BLUE ASH, OH 45242-3744
(513) 569-3741
(513) 569-3941
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
0101056490
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1295715324
—
VA
01
—
294885
ANTHEM
—
Enumeration date
01/17/2006
Last updated
06/04/2021
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