Basic Information
| Provider Information | |||||||||
| NPI: | 1891949830 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLYG | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILGENBURG | ||||||||
| OtherFirstName: | HEIDI | ||||||||
| OtherMiddleName: | MARIE | ||||||||
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| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3801 MIRANDA AVENUE | ||||||||
| Address2: | VA PALO ALTO HEALTH CARE SYSTEM (640/112) | ||||||||
| City: | PALO ALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6504935000 | ||||||||
| FaxNumber: | 6504962529 | ||||||||
| Practice Location | |||||||||
| Address1: | 3801 MIRANDA AVENUE | ||||||||
| Address2: | VA PALO ALTO HEALTH CARE SYSTEM (640/112) | ||||||||
| City: | PALO ALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6504935000 | ||||||||
| FaxNumber: | 6504962529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2008 | ||||||||
| LastUpdateDate: | 09/28/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WL0500X | 13437 | CA | N | Eye and Vision Services Providers | Optometrist | Low Vision Rehabilitation | 152W00000X | 13437 | CA | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | 2754 | CO | N | Eye and Vision Services Providers | Optometrist |
No ID Information.