Provider Demographics
NPI:1689761439
Name:IACOBUCCI, JOHN J (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:J
Last Name:IACOBUCCI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC-845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-391-1909
Mailing Address - Fax:616-391-8612
Practice Address - Street 1:221 MICHIGAN ST NE STE 300
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2537
Practice Address - Country:US
Practice Address - Phone:616-391-1909
Practice Address - Fax:616-391-8612
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010474932086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3397368Medicaid
MIOM43890Medicare ID - Type Unspecified
MI3397368Medicaid