Basic Information
Provider Information | |||||||||
NPI: | 1588673495 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HIESTER | ||||||||
FirstName: | ERIK | ||||||||
MiddleName: | DOUGLAS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 25487 | ||||||||
Address2: |   | ||||||||
City: | SARASOTA | ||||||||
State: | FL | ||||||||
PostalCode: | 342772487 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9412025342 | ||||||||
FaxNumber: | 8552534836 | ||||||||
Practice Location | |||||||||
Address1: | 7273 VANDERBILT BEACH RD STE 28 | ||||||||
Address2: |   | ||||||||
City: | NAPLES | ||||||||
State: | FL | ||||||||
PostalCode: | 341191479 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2393065390 | ||||||||
FaxNumber: | 2393065399 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/07/2006 | ||||||||
LastUpdateDate: | 12/23/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/23/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 230204 | NY | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207Q00000X | 230204 | NY | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | OS12128 | FL | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | HF963Z | 01 | FL | MEDICARE | OTHER | 008741800 | 05 | FL |   | MEDICAID | 14Q1Y | 01 | FL | BCBS | OTHER |