Provider Demographics
NPI:1255474813
Name:HEFFERON, KELLY (DO)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:HEFFERON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24567 NORTHWESTERN HWY
Mailing Address - Street 2:STE 150
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2421
Mailing Address - Country:US
Mailing Address - Phone:248-799-0093
Mailing Address - Fax:
Practice Address - Street 1:21650 W 11 MILE RD STE 209
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-3777
Practice Address - Country:US
Practice Address - Phone:248-809-9638
Practice Address - Fax:248-809-9996
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012396207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION64960Medicare ID - Type Unspecified