Provider Demographics
NPI:1063083343
Name:HEINRICH, CARL THEODORE IV
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:THEODORE
Last Name:HEINRICH
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7703 FLOYD CURL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3900
Mailing Address - Country:US
Mailing Address - Phone:210-567-7000
Mailing Address - Fax:
Practice Address - Street 1:7703 FLOYD CURL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3900
Practice Address - Country:US
Practice Address - Phone:210-567-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-07
Last Update Date:2023-06-26
Deactivation Date:2023-06-13
Deactivation Code:
Reactivation Date:2023-06-26
Provider Licenses
StateLicense IDTaxonomies
TXBP10082391390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program