Provider Demographics
NPI:1982960514
Name:DEYRO, HEIDI
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:DEYRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 E WALNUT ST
Mailing Address - Street 2:FL 3
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2160 S. FIRST AVENUE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-3282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-09
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA133814208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics