Provider Demographics
NPI:1568762953
Name:MICHAEL W HEASLET DPM INC
Entity Type:Organization
Organization Name:MICHAEL W HEASLET DPM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:KATHLEEN
Authorized Official - Last Name:HEASLET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-651-1202
Mailing Address - Street 1:4950 BARRANCA PKWY
Mailing Address - Street 2:SUITE 308
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-4671
Mailing Address - Country:US
Mailing Address - Phone:949-651-1202
Mailing Address - Fax:949-552-9493
Practice Address - Street 1:4950 BARRANCA PKWY
Practice Address - Street 2:SUITE 308
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4671
Practice Address - Country:US
Practice Address - Phone:949-651-1202
Practice Address - Fax:949-552-9493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2056213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1790735397OtherTYPE 1 NPI