Provider Demographics
NPI:1376626374
Name:GUTWEIN, HEATHER B (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:B
Last Name:GUTWEIN
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10853 E US HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-7981
Practice Address - Country:US
Practice Address - Phone:317-779-0606
Practice Address - Fax:317-757-8140
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040358207Q00000X
IN01040358A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100127060Medicaid
ININ2586002OtherMEDICARE PTAN
INF35875Medicare UPIN
ININ2586002OtherMEDICARE PTAN
080158248Medicare PIN