Provider Demographics
NPI:1831324789
Name:DIEPERINK OPTHOLT, HEATHER INES (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:INES
Last Name:DIEPERINK OPTHOLT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:HEATHER
Other - Middle Name:INES
Other - Last Name:DIEPERINK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 786
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-0786
Mailing Address - Country:US
Mailing Address - Phone:312-206-1064
Mailing Address - Fax:708-991-2630
Practice Address - Street 1:30 E 15TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-3459
Practice Address - Country:US
Practice Address - Phone:312-206-1064
Practice Address - Fax:708-991-2630
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-21
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.122487207P00000X
FLME104613207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL145P0OtherBC BS
GA402257536AMedicaid
FLCD079ZMedicare PIN