Provider Demographics
NPI:1467406439
Name:HEIDELBERG, KAREN ANN (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:ANN
Last Name:HEIDELBERG
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 1:20400 LIVERNOIS AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-1348
Mailing Address - Country:US
Mailing Address - Phone:313-864-3766
Mailing Address - Fax:313-864-8134
Practice Address - Street 1:20400 LIVERNOIS AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-1348
Practice Address - Country:US
Practice Address - Phone:313-864-3766
Practice Address - Fax:313-864-8134
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066952207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3437329Medicaid
MI3437329Medicaid