Provider Demographics
NPI:1043260359
Name:HEISELMAN, DARELL (DO)
Entity Type:Individual
Prefix:
First Name:DARELL
Middle Name:
Last Name:HEISELMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1761 BEALL AVE
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-2342
Mailing Address - Country:US
Mailing Address - Phone:330-263-8428
Mailing Address - Fax:330-263-8190
Practice Address - Street 1:1761 BEALL AVE
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-2342
Practice Address - Country:US
Practice Address - Phone:330-263-8428
Practice Address - Fax:330-263-8190
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34002960207R00000X, 207RC0200X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0451005Medicaid
A79833Medicare UPIN
0487244Medicare PIN