Provider Demographics
NPI:1649243643
Name:HEFFERNAN, JOHN PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PHILIP
Last Name:HEFFERNAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:38 POWEL AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02840-2655
Mailing Address - Country:US
Mailing Address - Phone:401-847-2418
Mailing Address - Fax:401-619-1028
Practice Address - Street 1:38 POWEL AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-2655
Practice Address - Country:US
Practice Address - Phone:401-847-2418
Practice Address - Fax:401-619-1028
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD09513208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7006003Medicaid
RIF35486Medicare UPIN
RI7006003Medicaid