Healthcare Provider Details

I. General information

NPI: 1144377961
Provider Name (Legal Business Name): DAVID JAMES HEFFERNAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DUDLEY ST SUITE 470
PROVIDENCE RI
02905-3236
US

IV. Provider business mailing address

PO BOX 16149
RUMFORD RI
02916-0697
US

V. Phone/Fax

Practice location:
  • Phone: 401-553-8355
  • Fax: 401-868-2314
Mailing address:
  • Phone: 401-453-9625
  • Fax: 401-435-7069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD12524
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number42633
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberMD12524
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number42633
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: