Healthcare Provider Details

I. General information

NPI: 1619618535
Provider Name (Legal Business Name): NICHOLAS JOHN HEITMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 E 102ND ST FL 4
NEW YORK NY
10029-5204
US

IV. Provider business mailing address

1 GUSTAVE L LEVY PL
NEW YORK NY
10029-6504
US

V. Phone/Fax

Practice location:
  • Phone: 212-659-8554
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number342299
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: