Provider Demographics
NPI:1619036241
Name:MCCUNE, HEATHER K (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:K
Last Name:MCCUNE
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 1:429 COUNTRY CLUB DRIVE
Mailing Address - Street 2:#102
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065
Mailing Address - Country:US
Mailing Address - Phone:310-623-7272
Mailing Address - Fax:
Practice Address - Street 1:429 COUNTRY CLUB DRIVE
Practice Address - Street 2:#102
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065
Practice Address - Country:US
Practice Address - Phone:310-623-7272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50442207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G504420Medicaid
E33309Medicare UPIN