Basic Information
| Provider Information | |||||||||
| NPI: | 1255412631 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IACONO | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1869 | ||||||||
| Address2: | |||||||||
| City: | FLETCHER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287321869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286876282 | ||||||||
| FaxNumber: | 8286876285 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 HOSPITAL DRIVE | ||||||||
| Address2: | SUITE 5-D | ||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287925247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286841030 | ||||||||
| FaxNumber: | 8286878229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 10/11/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0006X | 9600576 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 45040 | 01 | NC | BCBS | OTHER | 8945040 | 05 | NC | MEDICAID |