Basic Information
| Provider Information | |||||||||
| NPI: | 1649590910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEINISCH | ||||||||
| FirstName: | SILKE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 DISTEL CIR | ||||||||
| Address2: | |||||||||
| City: | LOS ALTOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940221408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102048168 | ||||||||
| FaxNumber: | 5105067721 | ||||||||
| Practice Location | |||||||||
| Address1: | 2850 TELEGRAPH AVE STE 130 | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947051159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102048168 | ||||||||
| FaxNumber: | 5105067721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2010 | ||||||||
| LastUpdateDate: | 06/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | MT197487 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207N00000X | 1053220 | CA | Y | Allopathic & Osteopathic Physicians | Dermatology | 207NP0225X | 1053220 | CA | N | Allopathic & Osteopathic Physicians | Dermatology | Pediatric Dermatology |
ID Information
| ID | Type | State | Issuer | Description | A130962 | 01 | CA | STATE MEDICAL LICENSE | OTHER |