Provider Demographics
NPI:1861483471
Name:HEUSINKVELD, DOMINIKA GRODZICKA (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIKA
Middle Name:GRODZICKA
Last Name:HEUSINKVELD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:DOMINIKA
Other - Middle Name:ANNA
Other - Last Name:GRODZICKA-TRUDGETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045-0600
Mailing Address - Country:US
Mailing Address - Phone:928-283-2458
Mailing Address - Fax:928-283-2677
Practice Address - Street 1:167 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045-0600
Practice Address - Country:US
Practice Address - Phone:928-283-2458
Practice Address - Fax:928-283-2677
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ43843207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO09529730Medicaid
NM05686202Medicaid
8HBW89Medicare PIN
H99170Medicare UPIN
CO09529730Medicaid
320059Medicare Oscar/Certification
8HBW90Medicare PIN