Provider Demographics
NPI:1932685823
Name:DE VERA, HEGINIO (PT)
Entity Type:Individual
Prefix:
First Name:HEGINIO
Middle Name:
Last Name:DE VERA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:
Practice Address - Street 1:7 W RIDGELY RD STE A
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-5135
Practice Address - Country:US
Practice Address - Phone:443-921-9890
Practice Address - Fax:410-252-4590
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-14
Last Update Date:2018-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21738225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty