Provider Demographics
NPI:1396070637
Name:THOELECKE, HEATHER (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:THOELECKE
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 1:720 WESTVIEW DR SW
Mailing Address - Street 2:DEPARTMENT OF SURGERY
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-1458
Mailing Address - Country:US
Mailing Address - Phone:361-244-8931
Mailing Address - Fax:404-616-6281
Practice Address - Street 1:720 WESTVIEW DR SW
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-1458
Practice Address - Country:US
Practice Address - Phone:361-244-8931
Practice Address - Fax:404-616-6281
Is Sole Proprietor?:No
Enumeration Date:2009-10-05
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96853207P00000X
GA004710208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine