Provider Demographics
NPI:1255373767
Name:HEGG, THEODORE D (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:D
Last Name:HEGG
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 1:307 S 13TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4109
Mailing Address - Country:US
Mailing Address - Phone:360-336-9757
Mailing Address - Fax:360-336-2088
Practice Address - Street 1:307 S 13TH ST STE 300
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4109
Practice Address - Country:US
Practice Address - Phone:360-336-9757
Practice Address - Fax:360-336-2088
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00014826174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8397804Medicaid
WAF00057Medicare UPIN
WAG000135043Medicare PIN