Healthcare Provider Details

I. General information

NPI: 1679511521
Provider Name (Legal Business Name): JOHN STEPHEN HEISEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 08/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BROOKLINE AVE
BOSTON MA
02215-3904
US

IV. Provider business mailing address

1493 CAMBRIDGE ST
CAMBRIDGE MA
02139-1047
US

V. Phone/Fax

Practice location:
  • Phone: 617-421-1157
  • Fax: 617-421-1063
Mailing address:
  • Phone: 617-665-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number36950
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number36950
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: