Provider Demographics
NPI:1053394742
Name:PELTZ, NICOLE R (DO)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:R
Last Name:PELTZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:RENEE
Other - Last Name:KACZANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27332 WOODWARD AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-0927
Mailing Address - Country:US
Mailing Address - Phone:248-543-1545
Mailing Address - Fax:248-543-8638
Practice Address - Street 1:27332 WOODWARD AVE
Practice Address - Street 2:STE 100
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-0927
Practice Address - Country:US
Practice Address - Phone:248-543-1545
Practice Address - Fax:248-543-8638
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014168208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
H84204Medicare UPIN