Provider Demographics
NPI:1861447245
Name:HESTON, THOMAS F (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:F
Last Name:HESTON
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 1:25 JACOBS GULCH RD
Mailing Address - Street 2:
Mailing Address - City:KELLOGG
Mailing Address - State:ID
Mailing Address - Zip Code:83837-2023
Mailing Address - Country:US
Mailing Address - Phone:208-783-1267
Mailing Address - Fax:
Practice Address - Street 1:25 JACOBS GULCH RD
Practice Address - Street 2:
Practice Address - City:KELLOGG
Practice Address - State:ID
Practice Address - Zip Code:83837-2023
Practice Address - Country:US
Practice Address - Phone:208-783-1267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6643207U00000X, 207Q00000X
WAMD00032355207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00305935OtherRAILROAD MEDICARE
WA423898078OtherGROUP HEALTH COOPERATIVE
WA0197912OtherL&I (REGULAR)
WA3976HEOtherREGENCE BLUESHIELD
ID804135600Medicaid
WA8192759Medicaid
WA8906064OtherL&I (CRIME VICTIM)
WA8192759Medicaid
WA3976HEOtherREGENCE BLUESHIELD
WA423898078OtherGROUP HEALTH COOPERATIVE