Healthcare Provider Details

I. General information

NPI: 1003317744
Provider Name (Legal Business Name): HEIDI DEARBORN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 LILLY RD SE
OLYMPIA WA
98501-2115
US

IV. Provider business mailing address

7300 RANCH ROAD 2222, BUILDING 1, STE 200
AUSTIN TX
78730
US

V. Phone/Fax

Practice location:
  • Phone: 360-485-4108
  • Fax:
Mailing address:
  • Phone: 512-628-0465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberDO2964
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberDO.OP.70058858
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: