Provider Demographics
NPI:1790748994
Name:MICHALAK, HEATHER A (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:A
Last Name:MICHALAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 NASHVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401
Mailing Address - Country:US
Mailing Address - Phone:931-388-8965
Mailing Address - Fax:931-388-0815
Practice Address - Street 1:1600 NASHVILLE HWY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401
Practice Address - Country:US
Practice Address - Phone:931-388-8965
Practice Address - Fax:931-388-0815
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238606208000000X
TNMD44004208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1511458Medicaid