Provider Demographics
NPI:1174765721
Name:BUONACCORSI, JANEEN NOELLE (MD)
Entity type:Individual
Prefix:DR
First Name:JANEEN
Middle Name:NOELLE
Last Name:BUONACCORSI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:J.
Other - Middle Name:NOELLE
Other - Last Name:BUONACCORSI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:530 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61637-0001
Mailing Address - Country:US
Mailing Address - Phone:309-624-9052
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-2050
Practice Address - Country:US
Practice Address - Phone:309-624-9052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-28
Last Update Date:2022-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106815207ND0900X
MN56826207ND0900X
CAA130023207ND0900X, 207ZP0102X
IL036138415207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN070001051Medicare PIN