Provider Demographics
NPI:1578534384
Name:DAMIANI, JOHN L (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:DAMIANI
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 1:214 E ELM AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-2678
Mailing Address - Country:US
Mailing Address - Phone:734-243-9620
Mailing Address - Fax:734-243-3565
Practice Address - Street 1:214 E ELM AVE STE 101
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162
Practice Address - Country:US
Practice Address - Phone:734-243-9620
Practice Address - Fax:734-243-3565
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34012721208800000X
MI5101010249208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4265480Medicaid
OH0238703Medicaid
OHH592500OtherMEDICARE PIN
MI0E06273OtherBCBSM
MI0H210660OtherBCBSM
MI0H26113011Medicare ID - Type Unspecified