Provider Demographics
NPI:1518923432
Name:HEFFERNAN, MICHAEL P (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:P
Last Name:HEFFERNAN
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 1:15 SANTA ROSA ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1811
Mailing Address - Country:US
Mailing Address - Phone:805-541-2650
Mailing Address - Fax:805-541-4043
Practice Address - Street 1:15 SANTA ROSA ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1811
Practice Address - Country:US
Practice Address - Phone:805-541-2650
Practice Address - Fax:805-541-4043
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35074557207N00000X
IN01072447A207N00000X
CAG80065207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201183400Medicaid
OH2601929Medicaid
4173991Medicare PIN
G89558Medicare UPIN
IN132590006Medicare PIN