Provider Demographics
NPI:1639102585
Name:HEFNER, RICHARD A (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:HEFNER
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:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-253-1035
Mailing Address - Fax:502-253-1037
Practice Address - Street 1:6580 KENWOOD CROSSINGS ROAD
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014
Practice Address - Country:US
Practice Address - Phone:502-243-3161
Practice Address - Fax:502-243-3164
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02614207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50023695OtherPASSPORT
KYP00774983OtherRAILROAD MEDICARE
KY000000609332OtherANTHEM
KY64000391Medicaid
KY3711039000OtherPASSPORT ADVANTAGE
KY50023695OtherPASSPORT
KY3711039000OtherPASSPORT ADVANTAGE