Provider Demographics
NPI:1679875223
Name:SCHICKEDANZ, HEATHER BENNETT (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:BENNETT
Last Name:SCHICKEDANZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:DAWN
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-319-4698
Mailing Address - Fax:
Practice Address - Street 1:1250 16TH ST STE A454
Practice Address - Street 2:SFVAMC BLDG 1, 300. MAIL 181G.
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1249
Practice Address - Country:US
Practice Address - Phone:310-319-4698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-01
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA115878207Q00000X, 208M00000X, 207RG0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program