Provider Demographics
NPI:1619089349
Name:HEITLAND, CHRISTOPHER DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:DEAN
Last Name:HEITLAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1278 GLENNEYRE ST
Mailing Address - Street 2:PMB 135
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-3103
Mailing Address - Country:US
Mailing Address - Phone:714-358-0457
Mailing Address - Fax:
Practice Address - Street 1:2220 E FRUIT ST
Practice Address - Street 2:SUITE 109
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-4459
Practice Address - Country:US
Practice Address - Phone:714-358-0457
Practice Address - Fax:714-541-8256
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA512172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF38168Medicare UPIN
CAA51217AMedicare ID - Type Unspecified