Provider Demographics
NPI:1902830755
Name:DONALDSON, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:DONALDSON
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 1:26025 LAHSER RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-2601
Mailing Address - Country:US
Mailing Address - Phone:248-663-1900
Mailing Address - Fax:248-663-1902
Practice Address - Street 1:26025 LAHSER RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-2601
Practice Address - Country:US
Practice Address - Phone:248-663-1900
Practice Address - Fax:248-663-1902
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085729207P00000X, 207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10377060OtherCMS
MI0767220001OtherADMINISTAR FEDERAL
MI4873214Medicaid
MI0F31114OtherBCBS
MI0F33583OtherBCBS DME
MI4873214Medicaid