Healthcare Provider Details

I. General information

NPI: 1972915627
Provider Name (Legal Business Name): JOHN TIMOTHY HEFFERNAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7308 BRIDGEPORT WAY W STE 201
LAKEWOOD WA
98499-8000
US

IV. Provider business mailing address

7308 BRIDGEPORT WAY W STE 201
LAKEWOOD WA
98499-8000
US

V. Phone/Fax

Practice location:
  • Phone: 253-582-7257
  • Fax: 253-582-1617
Mailing address:
  • Phone: 253-582-7257
  • Fax: 253-582-1617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD60968447
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: