Provider Demographics
NPI:1043322217
Name:HEROLD, HEIDI A (MD)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:A
Last Name:HEROLD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:WYCHANKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2300
Mailing Address - Fax:208-262-2390
Practice Address - Street 1:315 W DALTON AVE STE B
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8600
Practice Address - Country:US
Practice Address - Phone:208-209-2066
Practice Address - Fax:208-209-2076
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-13072207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1043322217Medicaid
CA20-2622913OtherTAX ID#
CA00A860570Medicare ID - Type Unspecified