Provider Demographics
NPI:1588667117
Name:MACKLEM, HEATHER A (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:A
Last Name:MACKLEM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2968
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46515-2968
Mailing Address - Country:US
Mailing Address - Phone:574-296-3955
Mailing Address - Fax:574-296-3999
Practice Address - Street 1:2115 W LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1423
Practice Address - Country:US
Practice Address - Phone:574-296-3955
Practice Address - Fax:574-296-3999
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048989A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN227950SSMedicare PIN
INH27555Medicare UPIN