Provider Demographics
NPI:1477526945
Name:HEGARTY, DECLAN F (MD)
Entity Type:Individual
Prefix:
First Name:DECLAN
Middle Name:F
Last Name:HEGARTY
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:PO BOX 1007
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-1007
Mailing Address - Country:US
Mailing Address - Phone:601-766-0308
Mailing Address - Fax:601-766-0309
Practice Address - Street 1:57 DEWEY ST
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-5707
Practice Address - Country:US
Practice Address - Phone:601-766-0308
Practice Address - Fax:601-766-0309
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94859208600000X
MS25465208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS25465OtherMS MEDICAL LICENSURE
FL1477526945OtherNPI
FL277709600Medicaid