Healthcare Provider Details

I. General information

NPI: 1477590461
Provider Name (Legal Business Name): PETER V VAITKEVICIUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 07/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18181 OAKWOOD BLVD SUITE 101
DEARBORN MI
48124-0000
US

IV. Provider business mailing address

18181 OAKWOOD BLVED SUITE 101
DEARBORN MI
48124
US

V. Phone/Fax

Practice location:
  • Phone: 313-996-7280
  • Fax:
Mailing address:
  • Phone: 313-996-7280
  • Fax: 313-996-7295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4301049384
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301049384
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number4301049384
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: