Basic Information
| Provider Information | |||||||||
| NPI: | 1063467751 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEINRICH | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | THOMAS | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5040 | ||||||||
| Address2: | |||||||||
| City: | OROVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305328584 | ||||||||
| FaxNumber: | 5305328433 | ||||||||
| Practice Location | |||||||||
| Address1: | 1611 FEATHER RIVER BLVD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | OROVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305344530 | ||||||||
| FaxNumber: | 5305328290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 01/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A5375 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00AX53750 | 05 | CA | MEDICAID |