Healthcare Provider Details

I. General information

NPI: 1689761439
Provider Name (Legal Business Name): JOHN J IACOBUCCI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 MICHIGAN ST NE STE 300
GRAND RAPIDS MI
49503-2537
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC-845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-1909
  • Fax: 616-391-8612
Mailing address:
  • Phone: 616-391-1909
  • Fax: 616-391-8612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number4301047493
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: