Provider Demographics
NPI:1982815130
Name:HEARTSILL, COLLEEN KELLY (MD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:KELLY
Last Name:HEARTSILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:E
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3605 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-6884
Mailing Address - Country:US
Mailing Address - Phone:325-949-9555
Mailing Address - Fax:
Practice Address - Street 1:3501 KNICKERBOCKER RD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-7610
Practice Address - Country:US
Practice Address - Phone:325-949-9555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-26
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4835207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB101228Medicare PIN