Provider Demographics
NPI:1154701076
Name:CLOUM, HEATHER MECHELLE (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:MECHELLE
Last Name:CLOUM
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:MIRA
Other - Middle Name:DIVYESHBHAI
Other - Last Name:KAKADIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:29624 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1296
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:875 S ROUTE 31
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-8190
Practice Address - Country:US
Practice Address - Phone:779-220-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-05
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI73987-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100138777Medicaid