Provider Demographics
NPI:1679619241
Name:HEISTERKAMP, GEORGIA E (MD)
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:E
Last Name:HEISTERKAMP
Suffix:
Gender:F
Credentials:MD
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 850
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362
Mailing Address - Country:US
Mailing Address - Phone:360-565-9237
Mailing Address - Fax:360-417-0127
Practice Address - Street 1:907 GEORGIANA ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3911
Practice Address - Country:US
Practice Address - Phone:360-565-0999
Practice Address - Fax:360-417-0127
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037379208600000X
CO46728208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB08976Medicare ID - Type Unspecified
COCOB4107Medicare PIN
COP00662388Medicare UPIN
G11933Medicare UPIN
WA1107127Medicaid
WA129307OtherL & I
CO22305297Medicaid
CO311442832001OtherROCKY MOUNTAIN HEALTH PLAN
G11933Medicare UPIN