Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0200X | Radiology | X002652 | NY |
Y | 213ER0200X | Radiology | X002652 | NY |
NPI | 1629153036 |
---|---|
Provider Name | Dr. Mark Steven Heffron |
First Address | Queens Village, NY 11427-1012 |
Second Address | Queens Village, NY 11427-1012 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/10/2006 |
Last Update Date | 17/07/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0079854 | GHI PROVIDER NUMBER (01) | NY |
11-2847332 | TAX ID (01) | NY |