Provider Demographics
NPI:1154633618
Name:HEFTY, MATTHEW TAYLOR (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:TAYLOR
Last Name:HEFTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E 1ST ST STE 316
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3190
Mailing Address - Country:US
Mailing Address - Phone:815-285-5842
Mailing Address - Fax:
Practice Address - Street 1:215 E 1ST ST STE 316
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3190
Practice Address - Country:US
Practice Address - Phone:815-285-5842
Practice Address - Fax:815-285-5845
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036147642208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400525521OtherMEDICARE PTAN
MI4301096886OtherEDUCATIONAL LIMITED LICENSE
IL376897OtherHEALTH ALLIANCE PROVIDER NUMBER