Provider Demographics
NPI:1629563572
Name:HEDER, MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HEDER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 N 500 W
Mailing Address - Street 2:ATTN CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:1300 S US-89
Practice Address - Street 2:
Practice Address - City:HEBER
Practice Address - State:UT
Practice Address - Zip Code:84032
Practice Address - Country:US
Practice Address - Phone:435-657-8000
Practice Address - Fax:435-657-8001
Is Sole Proprietor?:No
Enumeration Date:2018-06-23
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
UT12292652-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program