Healthcare Provider Details

I. General information

NPI: 1013114610
Provider Name (Legal Business Name): DAVID MICHAEL HEFNER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16490 W 78TH ST
EDEN PRAIRIE MN
55346-4300
US

IV. Provider business mailing address

215 DON KNOTTS BLVD
MORGANTOWN WV
26501-6734
US

V. Phone/Fax

Practice location:
  • Phone: 952-934-5332
  • Fax:
Mailing address:
  • Phone: 304-291-3627
  • Fax: 304-284-8667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS015131
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2341
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: