Provider Demographics
NPI:1205911237
Name:BROOKENTHAL, HEIDI SHARON (DO)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:SHARON
Last Name:BROOKENTHAL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2535 S KING DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-4746
Mailing Address - Country:US
Mailing Address - Phone:312-842-7117
Mailing Address - Fax:708-503-3993
Practice Address - Street 1:2535 S KING DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-4746
Practice Address - Country:US
Practice Address - Phone:708-747-7960
Practice Address - Fax:708-503-3993
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103288207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103288Medicaid
AZ867913Medicaid
IN200391070Medicaid
IL795650Medicare ID - Type Unspecified
IN200391070Medicaid
ILH43264Medicare UPIN