Basic Information
| Provider Information | |||||||||
| NPI: | 1730127903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEASLEY | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | CRESSLER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HEASLEY | ||||||||
| OtherFirstName: | DAVID | ||||||||
| OtherMiddleName: | CRESSLER | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | JR. | ||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 816 W CANNON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173210404 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8440 WALNUT HILL LN | ||||||||
| Address2: | SUITE 510 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752313833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143454406 | ||||||||
| FaxNumber: | 2143455543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 03/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | M0753 | TX | N | Other Service Providers | Specialist | 2085N0700X | M0753 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | M0753 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 083687601 | 05 | TX | MEDICAID |