Provider Demographics
NPI:1245345610
Name:HEINECK, SUSAN MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARIE
Last Name:HEINECK
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 1:20108 VICTORIA CHASE RD
Mailing Address - Street 2:
Mailing Address - City:LAGO VISTA
Mailing Address - State:TX
Mailing Address - Zip Code:78645-6311
Mailing Address - Country:US
Mailing Address - Phone:503-507-8701
Mailing Address - Fax:
Practice Address - Street 1:1215 E COURT ST
Practice Address - Street 2:
Practice Address - City:SEGUIN
Practice Address - State:TX
Practice Address - Zip Code:78155-5129
Practice Address - Country:US
Practice Address - Phone:830-379-2411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23510207P00000X
TXQ7204207P00000X, 207R00000X
NMMD2016-0139207P00000X
ALMD.34932207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287063Medicaid
OR287063Medicaid
G03122Medicare UPIN