Provider Demographics
NPI:1598738213
Name:HEITBRINK, MARK JOHN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:HEITBRINK
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11304 HAWTHORNE DR
Practice Address - Street 2:STE 100
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227-9425
Practice Address - Country:US
Practice Address - Phone:704-545-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9401208207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8941353Medicaid
NC2205968FMedicare PIN
NC8941353Medicaid
NCA80166Medicare UPIN