Provider Demographics
NPI:1306870761
Name:HEGSTAD, SUMIKO JOAN (MD)
Entity type:Individual
Prefix:DR
First Name:SUMIKO
Middle Name:JOAN
Last Name:HEGSTAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:J
Other - Last Name:HEGSTAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:222 N 2ND ST STE 102
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6129
Mailing Address - Country:US
Mailing Address - Phone:208-344-1281
Mailing Address - Fax:208-344-1696
Practice Address - Street 1:222 N 2ND ST STE 102
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6129
Practice Address - Country:US
Practice Address - Phone:208-344-1281
Practice Address - Fax:208-344-1696
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6778208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDG12430Medicare UPIN