Provider Demographics
NPI:1871816785
Name:DEITCH, HEIDI LYN (DO)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:LYN
Last Name:DEITCH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:LYN
Other - Last Name:FAGERLUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 231189
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92023-1189
Mailing Address - Country:US
Mailing Address - Phone:760-230-2251
Mailing Address - Fax:760-230-2253
Practice Address - Street 1:354 SANTA FE DR
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5142
Practice Address - Country:US
Practice Address - Phone:760-230-2251
Practice Address - Fax:760-230-2253
Is Sole Proprietor?:No
Enumeration Date:2010-03-05
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11120207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGB721ZMedicare PIN