Provider Demographics
NPI:1659400976
Name:HEINICKE, MARK H (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:H
Last Name:HEINICKE
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 1:332 W BROADWAY STE 217
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-2114
Mailing Address - Country:US
Mailing Address - Phone:502-589-2063
Mailing Address - Fax:
Practice Address - Street 1:332 W BROADWAY STE 217
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-2114
Practice Address - Country:US
Practice Address - Phone:502-589-2063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY21176207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64211766Medicaid
KY1329301Medicare ID - Type Unspecified
KY64211766Medicaid