Provider Demographics
NPI:1669444840
Name:VERGOS, PETER (OD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:VERGOS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3385 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1457
Mailing Address - Country:US
Mailing Address - Phone:810-244-3434
Mailing Address - Fax:810-715-0301
Practice Address - Street 1:3385 S CENTER RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48519-1457
Practice Address - Country:US
Practice Address - Phone:810-244-3434
Practice Address - Fax:810-715-0301
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003310152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPV003310OtherBCVISION
MI1093470001OtherMCSUPPLY
MI900B56331OtherBC NETWORK
MI900B567090OtherBCBS
MIU56358Medicare UPIN
MI900B567090OtherBCBS
MI0M11270Medicare PIN