Provider Demographics
NPI:1144267121
Name:IACOBELLI, JOAN WEBER (MD)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:WEBER
Last Name:IACOBELLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2864 WELLNESS AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8335
Mailing Address - Country:US
Mailing Address - Phone:386-775-0333
Mailing Address - Fax:386-775-0427
Practice Address - Street 1:2864 WELLNESS AVE STE 200
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8335
Practice Address - Country:US
Practice Address - Phone:386-775-0333
Practice Address - Fax:386-775-0427
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16001208600000X
FLME 108529208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003413400Medicaid
AL051083966OtherBLUE CROSS BLUE SHIELD
AL000083966Medicaid
FL14C4YOtherBCBS
FL14C4YOtherBCBS
AL051083966OtherBLUE CROSS BLUE SHIELD
FLE89224Medicare UPIN