Provider Demographics
NPI:1821135427
Name:HEILALA, MATT A (DPM)
Entity Type:Individual
Prefix:DR
First Name:MATT
Middle Name:A
Last Name:HEILALA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 LAKE OTIS PKWY STE 312
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5231
Mailing Address - Country:US
Mailing Address - Phone:907-569-3668
Mailing Address - Fax:907-569-3669
Practice Address - Street 1:4100 LAKE OTIS PKWY STE 312
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5231
Practice Address - Country:US
Practice Address - Phone:907-569-3668
Practice Address - Fax:907-569-3669
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4087213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPD5195Medicaid
AKU71106Medicare UPIN
AKK151475Medicare ID - Type Unspecified