Provider Demographics
NPI:1093791121
Name:HEFFERNAN, JOHN T (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:HEFFERNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J.
Other - Middle Name:TIMOTHY
Other - Last Name:HEFFERNAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:34719 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8714
Mailing Address - Country:US
Mailing Address - Phone:206-212-2100
Mailing Address - Fax:206-212-2194
Practice Address - Street 1:502 S M ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3728
Practice Address - Country:US
Practice Address - Phone:206-212-2100
Practice Address - Fax:206-212-2194
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016843207WX0200X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
3862HEOtherREGENCE HEALTHCARE
WA1777200Medicaid
180016727OtherRAILROAD MEDICARE
WA0036104OtherLABOR & INDUSTRIES
WA1777200Medicaid
G000150307Medicare PIN
WA0036104OtherLABOR & INDUSTRIES
3862HEOtherREGENCE HEALTHCARE