Provider Demographics
NPI:1013023092
Name:PESCHKE, HOWARD (DPM)
Entity Type:Individual
Prefix:
First Name:HOWARD
Middle Name:
Last Name:PESCHKE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13308 EDISON ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-1076
Mailing Address - Country:US
Mailing Address - Phone:734-282-4300
Mailing Address - Fax:
Practice Address - Street 1:13308 EDISON ST
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1076
Practice Address - Country:US
Practice Address - Phone:734-282-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901400131213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4384847Medicaid
MI5825179Medicare ID - Type UnspecifiedMEDICARE
MI4384847Medicaid
MI0P46860Medicare PIN