Provider Demographics
NPI:1487676854
Name:HEATHER, RICHARD EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:EDWARD
Last Name:HEATHER
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 1:2035 9TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93402-3209
Mailing Address - Country:US
Mailing Address - Phone:805-528-1812
Mailing Address - Fax:805-528-1843
Practice Address - Street 1:2035 9TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:LOS OSOS
Practice Address - State:CA
Practice Address - Zip Code:93402-3209
Practice Address - Country:US
Practice Address - Phone:805-528-1812
Practice Address - Fax:805-528-1843
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45637207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G456370Medicaid
CA10008648OtherRAILROAD RETIREMENT MC
CAE83323Medicare UPIN
CA00G456370Medicaid