Provider Demographics
NPI:1174589691
Name:HEIDGEN, DEBRA L (MD)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:L
Last Name:HEIDGEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 S. 4TH ST.
Mailing Address - Street 2:SUITE 120
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-5061
Mailing Address - Country:US
Mailing Address - Phone:913-772-6046
Mailing Address - Fax:913-758-0500
Practice Address - Street 1:3550 S. 4TH ST.
Practice Address - Street 2:SUITE 120
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-5061
Practice Address - Country:US
Practice Address - Phone:913-772-6046
Practice Address - Fax:913-758-0500
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-18860208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS017823Medicare PIN
F04020Medicare UPIN