Healthcare Provider Details

I. General information

NPI: 1891949830
Provider Name (Legal Business Name): HEIDI MARIE FLYG O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEIDI MARIE WILGENBURG O.D.

II. Dates (important events)

Enumeration Date: 11/04/2008
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 MIRANDA AVENUE VA PALO ALTO HEALTH CARE SYSTEM (640/112)
PALO ALTO CA
94304
US

IV. Provider business mailing address

3801 MIRANDA AVENUE VA PALO ALTO HEALTH CARE SYSTEM (640/112)
PALO ALTO CA
94304
US

V. Phone/Fax

Practice location:
  • Phone: 650-493-5000
  • Fax: 650-496-2529
Mailing address:
  • Phone: 650-493-5000
  • Fax: 650-496-2529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number13437
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13437
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2754
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: