Provider Demographics
NPI:1053346833
Name:HECIMOVICH, MICHAEL J (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:HECIMOVICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:ST 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0070
Mailing Address - Fax:
Practice Address - Street 1:3161 L ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5234
Practice Address - Country:US
Practice Address - Phone:916-453-9999
Practice Address - Fax:916-739-1099
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010120442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4247436Medicaid
MI3056306115OtherBCBS PIN #
MI310D460020OtherBCBS GROUP PIN
MI4247427Medicaid
MICA3518OtherMEDICARE RR GROUP PIN
MI0D46002018Medicare ID - Type UnspecifiedINDIVIDUAL #
MI3056306115OtherBCBS PIN #
MI310D460020OtherBCBS GROUP PIN
MI0D46002Medicare PIN
MI0F36125016Medicare PIN