Provider Demographics
NPI:1154840536
Name:MARDO, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:MARDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42017 DUXBURY DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-3473
Mailing Address - Country:US
Mailing Address - Phone:248-990-5314
Mailing Address - Fax:
Practice Address - Street 1:930 JOHN R RD APT 2129
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-4318
Practice Address - Country:US
Practice Address - Phone:248-990-5314
Practice Address - Fax:586-983-9604
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-17
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI87200835Medicaid