Provider Demographics
NPI:1518911908
Name:HEGGENESS, OLE A (DO)
Entity Type:Individual
Prefix:
First Name:OLE
Middle Name:A
Last Name:HEGGENESS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8255 FIRESTONE BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-4858
Mailing Address - Country:US
Mailing Address - Phone:562-231-2470
Mailing Address - Fax:562-231-2479
Practice Address - Street 1:8255 FIRESTONE BLVD STE 500
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241
Practice Address - Country:US
Practice Address - Phone:562-231-2470
Practice Address - Fax:562-231-2479
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4925207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00631832OtherRAILROAD
020A49250OtherBLUE SHIELD ID #
CA00AX49250Medicaid
520207OtherHEALTH NET ID #
010046850OtherRAILROAD
P00631832OtherRAILROAD
520207OtherHEALTH NET ID #
P00631832OtherRAILROAD
CAW20A4925HMedicare PIN