Provider Demographics
NPI:1598865602
Name:REDONDO, VICENTE (MD)
Entity Type:Individual
Prefix:
First Name:VICENTE
Middle Name:
Last Name:REDONDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:VICENTE
Other - Middle Name:
Other - Last Name:REDONDO-LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:46661 FIELDS DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-5135
Mailing Address - Country:US
Mailing Address - Phone:586-932-6331
Mailing Address - Fax:586-932-6366
Practice Address - Street 1:43134 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-1723
Practice Address - Country:US
Practice Address - Phone:586-446-8688
Practice Address - Fax:586-446-9994
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048942207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1105026191OtherBCBSMI PERSONAL PIN
MIVR048942OtherLICENSE PIN
MI2878632Medicaid
MI4749062Medicaid
MI2878632Medicaid
MI4749062Medicaid
MIM91190008Medicare PIN
MIM91190008Medicare PIN