Provider Demographics
NPI:1063641520
Name:HEDDERICH, MICHELLE SUZANNE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SUZANNE
Last Name:HEDDERICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:SUZANNE
Other - Last Name:RATHBUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2679 WINNEMISSETT OAKS DR
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-4862
Mailing Address - Country:US
Mailing Address - Phone:386-424-5000
Mailing Address - Fax:
Practice Address - Street 1:401 PALMETTO ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7322
Practice Address - Country:US
Practice Address - Phone:386-424-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME108171207Q00000X, 208M00000X
FL13489207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL13489OtherTRN