Provider Demographics
NPI:1720192479
Name:MACKAY, HEATHER A (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:MACKAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:A
Other - Last Name:MACKAY-GIMINO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 13129
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97309-1129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:875 OAK ST SE STE 5030
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3991
Practice Address - Country:US
Practice Address - Phone:503-814-3571
Practice Address - Fax:503-814-3577
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD28829207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN265415600Medicaid
MN0701250OtherMEDICA
MN31G86MAOtherBCBS
MN265415600Medicaid
MN1600001893Medicare ID - Type Unspecified