Provider Demographics
NPI:1164626388
Name:YODER-HEGDE, LIANA R (DO)
Entity Type:Individual
Prefix:
First Name:LIANA
Middle Name:R
Last Name:YODER-HEGDE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LIANA
Other - Middle Name:R
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:80 OLD RIVERHEAD RD
Mailing Address - Street 2:
Mailing Address - City:WESTHAMPTON BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11978-1401
Mailing Address - Country:US
Mailing Address - Phone:631-288-7746
Mailing Address - Fax:631-288-7111
Practice Address - Street 1:80 OLD RIVERHEAD RD
Practice Address - Street 2:
Practice Address - City:WESTHAMPTON BEACH
Practice Address - State:NY
Practice Address - Zip Code:11978-1401
Practice Address - Country:US
Practice Address - Phone:631-288-7746
Practice Address - Fax:631-288-7111
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244483207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY128Y3Medicare PIN