Provider Demographics
NPI:1013004373
Name:HEIDTKE, CLARE B (MD)
Entity Type:Individual
Prefix:
First Name:CLARE
Middle Name:B
Last Name:HEIDTKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 CHARLEVOIX AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8421
Mailing Address - Country:US
Mailing Address - Phone:231-487-0970
Mailing Address - Fax:231-487-0979
Practice Address - Street 1:2810 CHARLEVOIX AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8421
Practice Address - Country:US
Practice Address - Phone:231-487-0970
Practice Address - Fax:231-487-0979
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MICH045760207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3509689Medicaid
MI045760OtherBLUE CROSS BLUE SHEILD MI
MIE00453Medicare UPIN
MI0M74830Medicare ID - Type Unspecified