Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 024786 | CT |
N | 111NI0900X | Internist | 024786 | CT |
Y | 207RG0300X | Geriatric Medicine | 024786 | CT |
NPI | 1003875931 |
---|---|
Provider Name | Christian Heineken |
First Address | Bridgeport, CT 06606-4237 |
Second Address | Bridgeport, CT 06606-4237 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/03/2006 |
Last Update Date | 31/05/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
001247865 | (05) | CT |
D77072 | (02) | CT |