Provider Demographics
NPI:1255425807
Name:COUSINS, HEATHER T (M D)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:T
Last Name:COUSINS
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60000
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94160-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:795 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94301-2302
Practice Address - Country:US
Practice Address - Phone:650-330-4315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85210207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine