Provider Demographics
NPI:1629279187
Name:DAVID HESKIAOFF MD A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:DAVID HESKIAOFF MD A PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-784-3878
Mailing Address - Street 1:5170 SEPULVEDA BLVD
Mailing Address - Street 2:#100
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1171
Mailing Address - Country:US
Mailing Address - Phone:818-784-3878
Mailing Address - Fax:
Practice Address - Street 1:5170 SEPULVEDA BLVD
Practice Address - Street 2:#100
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1171
Practice Address - Country:US
Practice Address - Phone:818-784-3878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17201Medicare PIN