Provider Demographics
NPI:1912127945
Name:HECKERT, KIMBERLY GAIL DICUCCIO (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:GAIL DICUCCIO
Last Name:HECKERT
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 1:25 S 9TH ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4408
Mailing Address - Country:US
Mailing Address - Phone:215-955-1200
Mailing Address - Fax:215-923-6808
Practice Address - Street 1:25 S 9TH ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4408
Practice Address - Country:US
Practice Address - Phone:215-955-1200
Practice Address - Fax:215-923-6808
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08167900208100000X
PAMD428823208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0186953Medicaid
PA103099037Medicaid
NJ0186953Medicaid