Healthcare Provider Details

I. General information

NPI: 1659753614
Provider Name (Legal Business Name): WANDA HEFFERNON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2360 SCOUT RD
OAKLAND CA
94611-2724
US

IV. Provider business mailing address

2360 SCOUT RD
OAKLAND CA
94611-2724
US

V. Phone/Fax

Practice location:
  • Phone: 415-672-9861
  • Fax:
Mailing address:
  • Phone: 415-672-9861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG81259
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: