Provider Demographics
NPI:1083692925
Name:WILUSZ, PETER MICHAEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:MICHAEL
Last Name:WILUSZ
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 1:5730 BELLA ROSA BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-4774
Mailing Address - Country:US
Mailing Address - Phone:248-922-6000
Mailing Address - Fax:248-922-5997
Practice Address - Street 1:5730 BELLA ROSA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348
Practice Address - Country:US
Practice Address - Phone:248-922-6000
Practice Address - Fax:248-922-5997
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-31
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPW002033213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4858214660OtherBLUE CROSS BLUSE SHIELD
MI4856315560OtherBLUE CROSS
MI4940030 TYPE 13Medicaid
MI0P35210Medicare PIN
MIU93968Medicare UPIN