Provider Demographics
NPI:1205256757
Name:HEINRICH, DEMETRA (MD)
Entity type:Individual
Prefix:
First Name:DEMETRA
Middle Name:
Last Name:HEINRICH
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 1:610 30TH AVE W
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-3426
Mailing Address - Country:US
Mailing Address - Phone:320-763-2540
Mailing Address - Fax:
Practice Address - Street 1:610 30TH AVE W
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308
Practice Address - Country:US
Practice Address - Phone:320-763-2540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-23
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN63243207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1205256757Medicaid