Provider Demographics
NPI:1184719288
Name:HEINRICH, LORI A (MD)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:A
Last Name:HEINRICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:LORI
Other - Middle Name:A
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10303 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-5760
Mailing Address - Country:US
Mailing Address - Phone:262-240-0440
Mailing Address - Fax:262-240-0441
Practice Address - Street 1:10303 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5760
Practice Address - Country:US
Practice Address - Phone:262-240-0440
Practice Address - Fax:262-240-0441
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29744-020207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31824000Medicaid
WIF27900Medicare UPIN
WI02390Medicare ID - Type Unspecified