Provider Demographics
NPI:1396030102
Name:HEAFNER, THOMAS ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ANTHONY
Last Name:HEAFNER
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 1:60 MDG/60 SGCS/SGCH
Mailing Address - Street 2:101 BODIN CIR
Mailing Address - City:TRAVIS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:94535
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 MDG/60 SGCS/SGCH
Practice Address - Street 2:101 BODIN CIR
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535
Practice Address - Country:US
Practice Address - Phone:314-691-1352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-09
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT769152086S0129X
MN621452086S0129X
CAA1656532086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery