Provider Demographics
NPI:1699092130
Name:DANCKWART, HEATHER RAE (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:RAE
Last Name:DANCKWART
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 1:330 N 8TH AVE E
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2024
Mailing Address - Country:US
Mailing Address - Phone:218-723-1112
Mailing Address - Fax:218-529-9120
Practice Address - Street 1:330 N 8TH AVE E
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2024
Practice Address - Country:US
Practice Address - Phone:218-723-1112
Practice Address - Fax:218-529-9120
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN54082207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00978475OtherRR MEDICARE
MN1699092130Medicaid
1699092130OtherMEDICA
MN1699092130OtherBCBS
P00978475OtherRR MEDICARE