Healthcare Provider Details

I. General information

NPI: 1568762953
Provider Name (Legal Business Name): MICHAEL W HEASLET DPM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2010
Last Update Date: 11/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4950 BARRANCA PKWY SUITE 308
IRVINE CA
92604-4671
US

IV. Provider business mailing address

4950 BARRANCA PKWY SUITE 308
IRVINE CA
92604-4671
US

V. Phone/Fax

Practice location:
  • Phone: 949-651-1202
  • Fax: 949-552-9493
Mailing address:
  • Phone: 949-651-1202
  • Fax: 949-552-9493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE2056
License Number StateCA

VIII. Authorized Official

Name: MRS. GAIL KATHLEEN HEASLET
Title or Position: CORPORATE SECRETARY
Credential:
Phone: 949-651-1202