Healthcare Provider Details

I. General information

NPI: 1497767453
Provider Name (Legal Business Name): DAVID ROGER HEGLIN IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4643 DOCK RD BLDG 524
PORT HUENEME CA
93043-4321
US

IV. Provider business mailing address

4643 DOCK RD BLDG 524
PORT HUENEME CA
93043-4321
US

V. Phone/Fax

Practice location:
  • Phone: 805-982-2464
  • Fax: 805-982-3246
Mailing address:
  • Phone: 805-982-2464
  • Fax: 805-982-3246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: