Provider Demographics
NPI:1497900609
Name:RENDALL, HEIDI S (MD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:S
Last Name:RENDALL
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:P.O. BOX 959
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275
Mailing Address - Country:US
Mailing Address - Phone:425-347-1666
Mailing Address - Fax:425-355-5551
Practice Address - Street 1:8227 44TH AVE W.
Practice Address - Street 2:STE E
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275
Practice Address - Country:US
Practice Address - Phone:425-347-1666
Practice Address - Fax:425-355-5551
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019337207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A09258Medicare UPIN