Provider Demographics
NPI:1538456041
Name:HECKERT, ANNELIESE (DO)
Entity type:Individual
Prefix:DR
First Name:ANNELIESE
Middle Name:
Last Name:HECKERT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 BLAKE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GLENWOOD SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4288
Mailing Address - Country:US
Mailing Address - Phone:970-945-2840
Mailing Address - Fax:970-945-9581
Practice Address - Street 1:123 EMMA RD
Practice Address - Street 2:
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621-9169
Practice Address - Country:US
Practice Address - Phone:970-945-2840
Practice Address - Fax:970-945-2893
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO52789207Q00000X
COTL4126207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO90977548Medicaid
CO90977548Medicaid