Provider Demographics
NPI:1477660090
Name:HESHMATI, HEIDAR G (MD)
Entity Type:Individual
Prefix:MR
First Name:HEIDAR
Middle Name:G
Last Name:HESHMATI
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 1:2575 N COURTENAY PKWY
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953
Mailing Address - Country:US
Mailing Address - Phone:321-454-7111
Mailing Address - Fax:321-454-7129
Practice Address - Street 1:2575 N COURTENAY PKWY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953
Practice Address - Country:US
Practice Address - Phone:321-454-7111
Practice Address - Fax:321-454-7129
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMED0042145208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067540700Medicaid
P00188448OtherRAILROAD MEDICARE
D61240Medicare UPIN
05484ZMedicare ID - Type Unspecified