Provider Demographics
NPI:1013005578
Name:HEINZELMANN, MARK JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOSEPH
Last Name:HEINZELMANN
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 1:4701 TOWNE CENTRE, SUITE 104
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-8200
Mailing Address - Country:US
Mailing Address - Phone:989-790-1390
Mailing Address - Fax:989-790-1656
Practice Address - Street 1:4701 TOWNE CENTRE, SUITE 104
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-8200
Practice Address - Country:US
Practice Address - Phone:989-790-1390
Practice Address - Fax:989-790-1656
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046103174400000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2656699Medicaid
MI0730970Medicare ID - Type Unspecified