Healthcare Provider Details

I. General information

NPI: 1881413870
Provider Name (Legal Business Name): KYLE HERON MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4016 DALE RD
MODESTO CA
95356-9268
US

IV. Provider business mailing address

PO BOX 38865
BELFAST ME
04915-1230
US

V. Phone/Fax

Practice location:
  • Phone: 209-571-0288
  • Fax: 209-571-0327
Mailing address:
  • Phone: 209-571-0288
  • Fax: 209-571-0327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KYLE B HERON
Title or Position: OWNER
Credential: MD
Phone: 209-571-0288