Basic Information
| Provider Information | |||||||||
| NPI: | 1841307691 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IANCOVICI | ||||||||
| FirstName: | DORU | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 425 REVERE ST | ||||||||
| Address2: | |||||||||
| City: | REVERE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021514543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812861313 | ||||||||
| FaxNumber: | 7812861098 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 REVERE ST | ||||||||
| Address2: | |||||||||
| City: | REVERE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021514543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812861313 | ||||||||
| FaxNumber: | 7812861098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 02/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 73029 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3062902 | 05 | MA | MEDICAID |