Provider Demographics
NPI:1285686394
Name:HEILBRUNN, KEN S (MD)
Entity Type:Individual
Prefix:MR
First Name:KEN
Middle Name:S
Last Name:HEILBRUNN
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 1:545 ANDOVER PARK W
Mailing Address - Street 2:# 109
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188
Mailing Address - Country:US
Mailing Address - Phone:206-467-1949
Mailing Address - Fax:206-467-1912
Practice Address - Street 1:545 ANDOVER PARK W
Practice Address - Street 2:# 109
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188
Practice Address - Country:US
Practice Address - Phone:206-467-1949
Practice Address - Fax:206-467-1912
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00013791174400000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1055670Medicaid
WA10556760Medicaid
WA10556760Medicaid
WAB18186Medicare UPIN