Healthcare Provider Details

I. General information

NPI: 1982960514
Provider Name (Legal Business Name): HEIDI DEYRO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S. FIRST AVENUE
MAYWOOD IL
60153
US

IV. Provider business mailing address

393 E WALNUT ST FL 3
PASADENA CA
91188-0001
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-3282
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA133814
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: