Provider Demographics
NPI:1598797847
Name:HEYNEMAN, ELLEN K (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:K
Last Name:HEYNEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3020 CHILDRENS WAY
Mailing Address - Street 2:MAIL CODE 5018
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4223
Mailing Address - Country:US
Mailing Address - Phone:858-966-4935
Mailing Address - Fax:858-966-7525
Practice Address - Street 1:3020 CHILDRENS WAY
Practice Address - Street 2:MAIL CODE 5018
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4223
Practice Address - Country:US
Practice Address - Phone:858-966-4935
Practice Address - Fax:858-966-7525
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68996208000000X, 2084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G689960Medicaid
CA00G689960Medicaid
CAWG68996BMedicare ID - Type Unspecified