Provider Demographics
NPI:1265480248
Name:HEILICZER, JONATHAN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DAVID
Last Name:HEILICZER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:ST. CHRISTOPHER'S HOSPITAL FOR CHILDREN
Mailing Address - Street 2:ERIE AVENUE AT FRONT STREET
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-1095
Mailing Address - Country:US
Mailing Address - Phone:215-427-5190
Mailing Address - Fax:
Practice Address - Street 1:ST. CHRISTOPHER'S HOSPITAL FOR CHILDREN
Practice Address - Street 2:ERIE AVENUE AT FRONT STREET
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-1095
Practice Address - Country:US
Practice Address - Phone:215-427-5190
Practice Address - Fax:215-427-5351
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD4260082080P0210X
NJ25MA034881002080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012386320001Medicaid
PA1012386320001Medicaid
091202Medicare ID - Type Unspecified