Provider Demographics
NPI:1477879823
Name:GOLLOGLY, HEIDRUN (MD)
Entity Type:Individual
Prefix:DR
First Name:HEIDRUN
Middle Name:
Last Name:GOLLOGLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E CALIFORNIA BLVD
Mailing Address - Street 2:
Mailing Address - City:PASEDENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105
Mailing Address - Country:US
Mailing Address - Phone:626-269-5317
Mailing Address - Fax:
Practice Address - Street 1:5565 GROSSMONT CENTER DR STE 3
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942
Practice Address - Country:US
Practice Address - Phone:619-463-0331
Practice Address - Fax:619-463-0138
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105611207W00000X
MN54428207W00000X
CA134761207W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
MNENROLLEDMedicaid
MN180001521Medicare PIN