Healthcare Provider Details

I. General information

NPI: 1548351927
Provider Name (Legal Business Name): PAUL DAVID HEIDERSCHEIDT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FALLS CANYON RD
AVALON CA
90704-0000
US

IV. Provider business mailing address

762 BROOKRIDGE DR NE
ATLANTA GA
30306-3617
US

V. Phone/Fax

Practice location:
  • Phone: 310-510-0700
  • Fax: 310-510-2381
Mailing address:
  • Phone: 678-986-6453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA76682
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: