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General NPI Number Information
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NPI Number | 1861483471
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Entity Type | Individual
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Provider Name | DOMINIKA GRODZICKA HEUSINKVELD MD
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Gender | Female
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Dates
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Enumeration Date | 11/02/2005
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Last Update Date | 02/17/2014
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Provider Practice Location Address
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Address Line | 167 NORTH MAIN STREET
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City | TUBA CITY
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State | AZ
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Zip | 86045-0600
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Country | US
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Telephone | 928-283-2458
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Fax | 928-283-2677
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Provider Business Mailing Address
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Address Line | PO BOX 600
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City | TUBA CITY
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State | AZ
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Zip | 86045-0600
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Country | US
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Telephone | 928-283-2458
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Fax | 928-283-2677
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 43843
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License Number State | AZ
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