Healthcare Provider Details

I. General information

NPI: 1093791121
Provider Name (Legal Business Name): JOHN T. HEFFERNAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: J. TIMOTHY HEFFERNAN M.D.

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 S M ST
TACOMA WA
98405-3728
US

IV. Provider business mailing address

34719 6TH AVE S
FEDERAL WAY WA
98003-8714
US

V. Phone/Fax

Practice location:
  • Phone: 206-212-2100
  • Fax: 206-212-2194
Mailing address:
  • Phone: 206-212-2100
  • Fax: 206-212-2194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License NumberMD00016843
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD00016843
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: