Provider Demographics
NPI:1821087560
Name:FEDOR, PETER D (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:D
Last Name:FEDOR
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 308
Mailing Address - Street 2:
Mailing Address - City:ACME
Mailing Address - State:MI
Mailing Address - Zip Code:49610-0308
Mailing Address - Country:US
Mailing Address - Phone:231-947-1690
Mailing Address - Fax:231-947-1692
Practice Address - Street 1:872 MUNSON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3638
Practice Address - Country:US
Practice Address - Phone:231-947-1690
Practice Address - Fax:231-947-1692
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-16
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061885207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104609642Medicaid
MI104609633Medicaid
MI104609651Medicaid
MI104609660Medicaid
MI104609642Medicaid
MI104609660Medicaid