Provider Demographics
NPI:1548244056
Name:HEITZIG, DALE R (MD)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:R
Last Name:HEITZIG
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 1:610 SOLAREX CT
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-8624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 SOLAREX CT
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-8624
Practice Address - Country:US
Practice Address - Phone:301-682-5500
Practice Address - Fax:301-663-8557
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053129207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD926580505Medicaid
MDA651Medicare PIN
MD080125556Medicare PIN
MD451LMedicare PIN
MDCD8143Medicare PIN
MD926580505Medicaid
MDA651Medicare PIN