Provider Demographics
NPI:1750499034
Name:HEITZER, FREDERIC MARC (MD)
Entity Type:Individual
Prefix:
First Name:FREDERIC
Middle Name:MARC
Last Name:HEITZER
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 1:55 SCHANCK ROAD
Mailing Address - Street 2:SUITE A-12
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2963
Mailing Address - Country:US
Mailing Address - Phone:732-577-5525
Mailing Address - Fax:732-577-0045
Practice Address - Street 1:55 SCHANCK ROAD
Practice Address - Street 2:SUITE A-12
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2963
Practice Address - Country:US
Practice Address - Phone:732-577-5525
Practice Address - Fax:732-577-0045
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA04253000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1429604Medicaid
NJ186624Medicare ID - Type Unspecified
NJ1429604Medicaid