Healthcare Provider Details

I. General information

NPI: 1316681232
Provider Name (Legal Business Name): JOHN JEFFREY ITALIANO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6157 28TH ST SE STE 18B
GRAND RAPIDS MI
49546-6947
US

IV. Provider business mailing address

901 NORTH AVE NE APT A
GRAND RAPIDS MI
49503-1671
US

V. Phone/Fax

Practice location:
  • Phone: 616-282-5969
  • Fax:
Mailing address:
  • Phone: 231-672-8284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number5101027462
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101027462
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: