Provider Demographics
NPI:1720022205
Name:YOO, PETER J (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:YOO
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:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-3008
Mailing Address - Country:US
Mailing Address - Phone:517-364-9650
Mailing Address - Fax:517-364-9605
Practice Address - Street 1:1140 E MICHIGAN AVE STE 400
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1806
Practice Address - Country:US
Practice Address - Phone:517-364-9650
Practice Address - Fax:517-364-9605
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301092035207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1720022205Medicaid
CA00A758640Medicaid
CAG53820Medicare UPIN
CA00A758640Medicare ID - Type UnspecifiedPPIN
MIG53820Medicare UPIN
MI0C36345039Medicare PIN