Provider Demographics
NPI:1063467751
Name:HEINRICH, MARK THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:HEINRICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5040
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966
Mailing Address - Country:US
Mailing Address - Phone:530-532-8584
Mailing Address - Fax:530-532-8433
Practice Address - Street 1:1611 FEATHER RIVER BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95965
Practice Address - Country:US
Practice Address - Phone:530-534-4530
Practice Address - Fax:530-532-8290
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5375207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX53750Medicaid
CA020A53752Medicare ID - Type Unspecified
CA00AX53750Medicaid