Provider Demographics
NPI:1740871888
Name:HEITZ, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:HEITZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-5021
Mailing Address - Country:US
Mailing Address - Phone:704-930-9733
Mailing Address - Fax:
Practice Address - Street 1:3399 NORTH RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1350
Practice Address - Country:US
Practice Address - Phone:704-930-9733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY107695OtherN/A