1275761991 NPI number — DR. GREGORY HELLER D.O.

Table of content: DR. GREGORY HELLER D.O. (NPI 1275761991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275761991 NPI number — DR. GREGORY HELLER D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HELLER
Provider First Name:
GREGORY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275761991
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19389 N 59TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85308-6500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-537-6000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19389 N 59TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85308-6500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-537-6000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/01/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 204D00000X , with the licence number:  0102206528 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: R1704 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 006017 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: R1704 . This is a "TRAINING PERMIT" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".