Provider Demographics
NPI:1073958021
Name:HEINECKE, GILLIAN MEADE (MD)
Entity Type:Individual
Prefix:DR
First Name:GILLIAN
Middle Name:MEADE
Last Name:HEINECKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 S GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-1540
Mailing Address - Country:US
Mailing Address - Phone:314-256-3430
Mailing Address - Fax:
Practice Address - Street 1:1755 S GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1540
Practice Address - Country:US
Practice Address - Phone:314-256-3430
Practice Address - Fax:314-256-3431
Is Sole Proprietor?:No
Enumeration Date:2013-05-03
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020016507207N00000X
CAA132579207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology