Provider Demographics
NPI:1336643733
Name:PETER, VINOD SURENDRAKUMAR (RPT)
Entity Type:Individual
Prefix:MR
First Name:VINOD
Middle Name:SURENDRAKUMAR
Last Name:PETER
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 MISTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-5825
Mailing Address - Country:US
Mailing Address - Phone:734-673-1897
Mailing Address - Fax:734-844-0316
Practice Address - Street 1:1418 MISTWOOD CT
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-5825
Practice Address - Country:US
Practice Address - Phone:734-673-1897
Practice Address - Fax:734-844-0316
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005460225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist