Provider Demographics
NPI:1174500821
Name:VONDERAU, PETER E (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:E
Last Name:VONDERAU
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:P. O. BOX 715868
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19171-5868
Mailing Address - Country:US
Mailing Address - Phone:804-215-3063
Mailing Address - Fax:605-341-4501
Practice Address - Street 1:125 AKERS FARM ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-4867
Practice Address - Country:US
Practice Address - Phone:540-552-7133
Practice Address - Fax:540-251-3516
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD7446208100000X, 208VP0014X
VA0101277437208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1174500821OtherTLC ADVANTAGE, L.L.C.
SD1174500821Medicaid
SD1174500821OtherSANFORD HEALTH PLAN
SD1174500821OtherTRICARE
SD1174500821OtherWELLMARK BCBS
SD23-00706OtherMEDICA
SD1174500821OtherTLC ADVANTAGE, L.L.C.
SD23-00706OtherMEDICA