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General NPI Number Information
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NPI Number | 1316681232
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Entity Type | Individual
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Provider Name | JOHN JEFFREY ITALIANO DO
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Gender | Male
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Dates
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Enumeration Date | 04/26/2022
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Last Update Date | 12/03/2025
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Provider Practice Location Address
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Address Line | 6157 28TH ST SE STE 18B
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-6947
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Country | US
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Telephone | 616-282-5969
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Fax |
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Provider Business Mailing Address
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Address Line | 901 NORTH AVE NE APT A
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-1671
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Country | US
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Telephone | 231-672-8284
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 5101027462
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 5101027462
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License Number State | MI
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