Provider Demographics
NPI:1265467898
Name:HEETDERKS, PETER WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:WILLIAM
Last Name:HEETDERKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 HIGHWOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-0010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3024 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1247
Practice Address - Country:US
Practice Address - Phone:919-350-7270
Practice Address - Fax:919-350-7204
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01601207R00000X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902133Medicaid
NC2047146Medicare ID - Type Unspecified
NC5902133Medicaid