Provider Demographics
NPI:1073504122
Name:HEIDEMANN, DAVID G (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:G
Last Name:HEIDEMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:29201 TELEGRAPH RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1331
Mailing Address - Country:US
Mailing Address - Phone:248-350-1130
Mailing Address - Fax:248-350-2709
Practice Address - Street 1:29201 TELEGRAPH RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1331
Practice Address - Country:US
Practice Address - Phone:248-350-1130
Practice Address - Fax:248-350-2709
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301048651207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1818756Medicaid
B47170Medicare UPIN
06322697181Medicare ID - Type Unspecified