Basic Information
| Provider Information | |||||||||
| NPI: | 1578683231 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEIDT | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | GRAHAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 FRANK LLOYD WRIGHT DR LBBY J2000 | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481059484 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5301 E HURON RIVER DR | ||||||||
| Address2: | |||||||||
| City: | YPSILANTI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347127017 | ||||||||
| FaxNumber: | 7347122844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
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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 | 208600000X | 35.095889 | OH | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 4301077820 | MI | N | Allopathic & Osteopathic Physicians | Surgery | 390200000X | 4301077820 | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2086S0102X | 4301077820 | MI | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 3077576 | 05 | OH | MEDICAID |