Provider Demographics
NPI:1689618639
Name:GIACOBBO, KENNETH (DO)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:GIACOBBO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 WOODMONT BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-5250
Mailing Address - Country:US
Mailing Address - Phone:888-987-1151
Mailing Address - Fax:
Practice Address - Street 1:3506 CLARK RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-8408
Practice Address - Country:US
Practice Address - Phone:941-299-0114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05784100207R00000X
PAOS007502L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA485823VOBMedicare PIN
PAF49275Medicare UPIN
NJ061782V41Medicare PIN