=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922298223
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK ANDREW HEITNER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2007
-----------------------------------------------------
Last Update Date | 07/05/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1838 EL CAMINO #101
-----------------------------------------------------
City | BURLINGAME
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-644-0000
-----------------------------------------------------
Fax | 415-431-4407
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 912 COLE ST STE 350
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94117-4316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-644-0000
-----------------------------------------------------
Fax | 415-431-4407
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | G48243
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------