Healthcare Provider Details

I. General information

NPI: 1750849949
Provider Name (Legal Business Name): DEREK JORDAN HEUSSNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 06/15/2025
Certification Date: 06/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE # L10
CLEVELAND OH
44195-6712
US

IV. Provider business mailing address

9500 EUCLID AVE # L10
CLEVELAND OH
44195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-0617
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number35.152741
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: