Provider Demographics
NPI:1700854957
Name:HEFFERNAN, J MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:MICHAEL
Last Name:HEFFERNAN
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 1:50 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-3335
Mailing Address - Country:US
Mailing Address - Phone:610-372-8044
Mailing Address - Fax:484-334-7026
Practice Address - Street 1:950 N WYOMISSING BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-1784
Practice Address - Country:US
Practice Address - Phone:610-898-2400
Practice Address - Fax:610-376-5861
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030004E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011482470001Medicaid
PA0011482470001Medicaid
044166FHLMedicare ID - Type Unspecified