Provider Demographics
NPI:1093768244
Name:CAVACECE, JOHN (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CAVACECE
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 1:245 STATE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4328
Mailing Address - Country:US
Mailing Address - Phone:616-685-1808
Mailing Address - Fax:616-685-1850
Practice Address - Street 1:300 LAFAYETTE AVE SE
Practice Address - Street 2:SUITE 4200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4650
Practice Address - Country:US
Practice Address - Phone:616-685-6922
Practice Address - Fax:616-685-5105
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013293207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3364634Medicaid
MI4597031Medicaid
MI3290666Medicaid
MI3415564Medicaid
MI3495251Medicaid
MI4878391Medicaid
MIG35883Medicare UPIN
MI4878391Medicaid
MI4878060Medicare ID - Type Unspecified
MI3495251Medicaid
MIM02830058Medicare ID - Type Unspecified