Provider Demographics
NPI:1346244803
Name:GREGORY, PETER F (DPM)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:F
Last Name:GREGORY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17316 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-3158
Mailing Address - Country:US
Mailing Address - Phone:734-522-7676
Mailing Address - Fax:734-261-2130
Practice Address - Street 1:17316 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3158
Practice Address - Country:US
Practice Address - Phone:734-522-7676
Practice Address - Fax:734-261-2130
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-11
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000968213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI002571OtherMIDWEST
MI2107660Medicaid
480001655OtherRR MEDICARE
MI5821542OtherBLUE SHIELD
540H221640OtherBLUE SHIELD DME
540H221640OtherBLUE SHIELD DME
MI5825023Medicare PIN
MI002571OtherMIDWEST