Provider Demographics
NPI:1710156799
Name:HELLER, MICHELLE (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HELLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 ROUTE 10
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SUCCASUNNA
Mailing Address - State:NJ
Mailing Address - Zip Code:07876-1452
Mailing Address - Country:US
Mailing Address - Phone:973-584-0002
Mailing Address - Fax:973-584-7107
Practice Address - Street 1:151 ROUTE 10
Practice Address - Street 2:SUITE 105
Practice Address - City:SUCCASUNNA
Practice Address - State:NJ
Practice Address - Zip Code:07876-1452
Practice Address - Country:US
Practice Address - Phone:973-584-0002
Practice Address - Fax:973-584-7107
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08935800208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0267554Medicaid