Provider Demographics
NPI:1245420884
Name:HEFFERNAN, THOMAS E (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:HEFFERNAN
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 1:1331 N ELM ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-6302
Mailing Address - Country:US
Mailing Address - Phone:888-592-6045
Mailing Address - Fax:336-482-2177
Practice Address - Street 1:471 E BROAD ST
Practice Address - Street 2:SUITE 1400
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-3842
Practice Address - Country:US
Practice Address - Phone:888-592-6045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA026394390200000X
OH350932832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1090930Medicaid