Provider Demographics
NPI:1184679193
Name:MEMMEL MITIDIERO, HEIDI CHRISTINE (MD)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:CHRISTINE
Last Name:MEMMEL MITIDIERO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:C
Other - Last Name:MEMMEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1000 N WESTMORELAND RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1658
Mailing Address - Country:US
Mailing Address - Phone:847-582-2134
Mailing Address - Fax:847-535-7285
Practice Address - Street 1:1000 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1658
Practice Address - Country:US
Practice Address - Phone:847-582-2134
Practice Address - Fax:847-535-7285
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36107710208600000X
IL036107710208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery