Provider Demographics
NPI:1790735397
Name:HEASLET, MICHAEL WILLIAM (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:HEASLET
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4950 BARRANCA PKWY
Mailing Address - Street 2:SUITE 308
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-4671
Mailing Address - Country:US
Mailing Address - Phone:949-651-1202
Mailing Address - Fax:949-552-9493
Practice Address - Street 1:4950 BARRANCA PKWY
Practice Address - Street 2:SUITE 308
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4671
Practice Address - Country:US
Practice Address - Phone:949-651-1202
Practice Address - Fax:949-552-9493
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2056213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-3539063OtherFEDERAL TAX ID
CAE2056OtherSTATE LICENSE NUMBER
953539063OtherBILLING TIN
CAT11159Medicare UPIN
CA95-3539063OtherFEDERAL TAX ID