Provider Demographics
NPI:1477590461
Name:VAITKEVICIUS, PETER V (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:V
Last Name:VAITKEVICIUS
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 1:18181 OAKWOOD BLVED
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124
Mailing Address - Country:US
Mailing Address - Phone:313-996-7280
Mailing Address - Fax:313-996-7295
Practice Address - Street 1:18181 OAKWOOD BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-0000
Practice Address - Country:US
Practice Address - Phone:313-996-7280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301049384207RC0000X, 207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE23695Medicare UPIN