Provider Demographics
NPI:1063422749
Name:WARK, HEATHER (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:WARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:548 ELM ST
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-2832
Mailing Address - Country:US
Mailing Address - Phone:413-586-3150
Mailing Address - Fax:413-586-6321
Practice Address - Street 1:548 ELM ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-2832
Practice Address - Country:US
Practice Address - Phone:413-586-3150
Practice Address - Fax:413-774-7049
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA76508207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3143384Medicaid
MA25338OtherBMC HEALTHNET
MAJ16239OtherBC/BS MA
MAA20501Medicare ID - Type Unspecified
MA25338OtherBMC HEALTHNET