Provider Demographics
NPI:1790704401
Name:HEITZMAN, MARK ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
Last Name:HEITZMAN
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 547
Mailing Address - Street 2:CENTRAL VERMONT MEDICAL CENTER-FINANCE DEPT
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-0547
Mailing Address - Country:US
Mailing Address - Phone:802-225-5660
Mailing Address - Fax:802-229-9533
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:MOB-A SUITE 2-1
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9516
Practice Address - Country:US
Practice Address - Phone:802-225-5660
Practice Address - Fax:802-229-2533
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT420006618207RI0011X
VT042.0006618207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0005341Medicaid
VTP01125405OtherRAILROAD MEDICARE LINKED TO CVMC MGP
VT060014973OtherRAIL ROAD MEDICARE
VT060014973OtherRAIL ROAD MEDICARE
VTP01125405OtherRAILROAD MEDICARE LINKED TO CVMC MGP
VTBX3998Medicare PIN
VTVT5341Medicare PIN
VTVT534101Medicare PIN