Provider Demographics
NPI:1457382079
Name:HEIFETZ, LAURENCE JAY (MD)
Entity type:Individual
Prefix:
First Name:LAURENCE
Middle Name:JAY
Last Name:HEIFETZ
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 1:10121 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-4835
Mailing Address - Country:US
Mailing Address - Phone:530-582-6450
Mailing Address - Fax:530-582-6430
Practice Address - Street 1:10956 DONNER PASS RD
Practice Address - Street 2:SUITE 210
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-4861
Practice Address - Country:US
Practice Address - Phone:530-582-6450
Practice Address - Fax:530-550-8169
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG26341207RX0202X
TXF0507207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00G263410Medicare ID - Type Unspecified
B51007Medicare UPIN