Provider Demographics
NPI:1821085952
Name:HIESTAND, JOHN JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JOSEPH
Last Name:HIESTAND
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 1:2239 AUGUSTA DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-9130
Mailing Address - Country:US
Mailing Address - Phone:419-355-8208
Mailing Address - Fax:
Practice Address - Street 1:2575 HAYES AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-5201
Practice Address - Country:US
Practice Address - Phone:419-332-1551
Practice Address - Fax:419-332-1132
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-061218207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0828699OtherBCMH
OH4269829OtherAETNA
OH0828699Medicaid
OH110049825OtherRAILROAD RETIREES
OH36D067581OtherCLIA
OH000000028816OtherANTHEM
OHHI 0696121Medicare ID - Type Unspecified
OH0828699Medicaid