Provider Demographics
NPI:1093913584
Name:PADDOCK, HEATHER N (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:N
Last Name:PADDOCK
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 1:2160 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-327-2697
Mailing Address - Fax:708-327-3565
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:BLDG 110, ROOM 3225
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-327-2697
Practice Address - Fax:708-327-3565
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-020862086S0120X
IL036.1290112086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5914201Medicaid