Healthcare Provider Details

I. General information

NPI: 1659602811
Provider Name (Legal Business Name): MICHAEL DOUGLAS HEGEWALD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2010
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2004 BROADWAY ST
VANCOUVER WA
98663-3327
US

IV. Provider business mailing address

4204 NE 44TH ST
VANCOUVER WA
98661
US

V. Phone/Fax

Practice location:
  • Phone: 360-993-8868
  • Fax:
Mailing address:
  • Phone: 360-921-8377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA60117362
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: