Provider Demographics
NPI:1679511521
Name:HEISEL, JOHN STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:STEPHEN
Last Name:HEISEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1493 CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1047
Mailing Address - Country:US
Mailing Address - Phone:617-665-1000
Mailing Address - Fax:
Practice Address - Street 1:133 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3904
Practice Address - Country:US
Practice Address - Phone:617-421-1157
Practice Address - Fax:617-421-1063
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA369502084P0805X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0037411OtherNEIGHBORHOOD HEALTH PLAN
MA036950OtherTUFTS HEALTH PLAN
MAB07139OtherBLUE CROSS
MA036950OtherTUFTS HEALTH PLAN
MAB07139OtherBLUE CROSS