Active NPI
Larry Ira Heiss, MD
- Family Medicine Physician
- Fort Bragg, CA
National Provider Identifier
1629192687
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- G28236
- Practice address
- 205 South St
Fort Bragg, CA 95437-5540 - Phone
- (707) 964-1251
- Fax
- (707) 961-2722
- NPI assigned
- Mar 16, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | G28236 | CA | Primary |
Addresses
Primary practice location
205 South St
Fort Bragg, CA 95437-5540
Mailing address
205 South St
Fort Bragg, CA 95437-5540
Phone (707) 964-1251
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| FHC03967F | Medicaid | CA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| G28236 | CA | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Pacific Redwood Medical Group Inc | Family Medicine | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
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Family Medicine
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1174003200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1407715200000",
"number": "1629192687",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "205 SOUTH ST",
"city": "FORT BRAGG",
"state": "CA",
"postal_code": "954375540",
"telephone_number": "707-964-1251",
"fax_number": "707-961-2722"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "205 SOUTH ST",
"city": "FORT BRAGG",
"state": "CA",
"postal_code": "954375540",
"telephone_number": "707-964-1251",
"fax_number": "707-961-2722"
}
],
"practiceLocations": [],
"basic": {
"last_name": "HEISS",
"first_name": "LARRY",
"middle_name": "IRA",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-03-16",
"last_updated": "2014-08-11",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "CA",
"license": "G28236",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "FHC03967F",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Fort Bragg, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 11, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.