Healthcare Provider Details

I. General information

NPI: 1629036801
Provider Name (Legal Business Name): RANDY V HEYSEK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 11/27/2023
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40107 HWY 27
DAVENPORT FL
33837
US

IV. Provider business mailing address

PO BOX 90758
LAKELAND FL
33804-0758
US

V. Phone/Fax

Practice location:
  • Phone: 863-419-0692
  • Fax: 863-419-1695
Mailing address:
  • Phone: 407-566-9899
  • Fax: 407-566-9893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberME51222
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: