Provider Demographics
NPI:1003875931
Name:HEINEKEN, CHRISTIAN (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:
Last Name:HEINEKEN
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 1:3180 MAIN ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4237
Mailing Address - Country:US
Mailing Address - Phone:203-373-9100
Mailing Address - Fax:203-365-8492
Practice Address - Street 1:3180 MAIN ST
Practice Address - Street 2:SUITE 301
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4237
Practice Address - Country:US
Practice Address - Phone:203-373-9100
Practice Address - Fax:203-365-8492
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT024786207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001247865Medicaid
CT110006316Medicare ID - Type Unspecified
CT001247865Medicaid