Provider Demographics
NPI:1699859611
Name:HEISTAND, MICHAEL (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:HEISTAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8042 WURZBACH SUITE 350
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229
Mailing Address - Country:US
Mailing Address - Phone:210-614-3412
Mailing Address - Fax:
Practice Address - Street 1:8042 WURZBACH SUITE 350
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229
Practice Address - Country:US
Practice Address - Phone:210-614-3412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD8L63207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
T302Medicare ID - Type Unspecified
B23412Medicare UPIN