Provider Demographics
NPI:1316046790
Name:MATT A. HEILALA, DPM INC.
Entity type:Organization
Organization Name:MATT A. HEILALA, DPM INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:A
Authorized Official - Last Name:HEILALA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:907-569-3668
Mailing Address - Street 1:4100 LAKE OTIS PKWY
Mailing Address - Street 2:SUITE 312
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5222
Mailing Address - Country:US
Mailing Address - Phone:907-569-3668
Mailing Address - Fax:907-569-3669
Practice Address - Street 1:4100 LAKE OTIS PKWY
Practice Address - Street 2:SUITE 312
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5222
Practice Address - Country:US
Practice Address - Phone:907-569-3668
Practice Address - Fax:907-569-3669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3497213ES0103X
AK4087213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPD5195Medicaid
AKPD3497Medicaid
AKK152827Medicare ID - Type Unspecified
AKK160293Medicare ID - Type Unspecified
AKPD3497Medicaid
AKU71106Medicare UPIN
AKPD5195Medicaid