Provider Demographics
NPI:1770672859
Name:MCNULTY, HEIDI (DO)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 W COVELL BLVD
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-5671
Mailing Address - Country:US
Mailing Address - Phone:530-747-3095
Mailing Address - Fax:
Practice Address - Street 1:2660 W COVELL BLVD
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-5645
Practice Address - Country:US
Practice Address - Phone:540-747-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A14014207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F19891Medicare UPIN