Healthcare Provider Details

I. General information

NPI: 1487676854
Provider Name (Legal Business Name): RICHARD EDWARD HEATHER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2035 9TH ST SUITE A
LOS OSOS CA
93402-3209
US

IV. Provider business mailing address

2035 9TH ST SUITE A
LOS OSOS CA
93402-3209
US

V. Phone/Fax

Practice location:
  • Phone: 805-528-1812
  • Fax: 805-528-1843
Mailing address:
  • Phone: 805-528-1812
  • Fax: 805-528-1843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG45637
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: