Provider Demographics
NPI:1174544928
Name:DODENHOFF, PETER CHARLES (DO, PC)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:CHARLES
Last Name:DODENHOFF
Suffix:
Gender:M
Credentials:DO, PC
Other - Prefix:
Other - First Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21811 KELLY RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021
Mailing Address - Country:US
Mailing Address - Phone:586-773-0200
Mailing Address - Fax:586-773-9803
Practice Address - Street 1:21811 KELLY RD
Practice Address - Street 2:SUITE 107
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021
Practice Address - Country:US
Practice Address - Phone:586-773-0200
Practice Address - Fax:586-773-9803
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006192207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI55033895OtherBCBS
MI1075599110Medicaid
MI1075599110Medicaid
55033898021Medicare ID - Type Unspecified