Basic Information
| Provider Information | |||||||||
| NPI: | 1033128475 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HECKER | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 323 S 18TH AVE | ||||||||
| Address2: | |||||||||
| City: | STURGEON BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542351401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207460510 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 323 S 18TH AVE | ||||||||
| Address2: | |||||||||
| City: | STURGEON BAY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542351401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9207460510 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 06/17/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 351025 | WI | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 43212700 | 05 | WI | MEDICAID |