Provider Demographics
NPI:1104903228
Name:HEGGELAND, RICHARD L (OD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:HEGGELAND
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:#14
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6737
Mailing Address - Country:US
Mailing Address - Phone:770-271-0611
Mailing Address - Fax:770-271-5525
Practice Address - Street 1:1000 PEACHTREE INDUSTRIAL BLVD STE 14
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1977
Practice Address - Country:US
Practice Address - Phone:770-271-0611
Practice Address - Fax:770-271-5525
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA756 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G700808Medicare PIN