Basic Information
| Provider Information | |||||||||
| NPI: | 1700984911 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEIDENFELDER | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 STRATFORD AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910303417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194354088 | ||||||||
| FaxNumber: | 6194354088 | ||||||||
| Practice Location | |||||||||
| Address1: | 3133 N MILLBROOK AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937031425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596008918 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 06/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | A79836 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | A79836 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 7829036 | 05 | CA | MEDICAID |