Provider Demographics
NPI:1053591644
Name:DOREAU, HEIDI RAY (NP)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:RAY
Last Name:DOREAU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 BEDFORD STREET
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420
Mailing Address - Country:US
Mailing Address - Phone:781-274-6274
Mailing Address - Fax:781-862-1472
Practice Address - Street 1:450 BEDFORD STREET
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420
Practice Address - Country:US
Practice Address - Phone:781-274-6274
Practice Address - Fax:781-862-1472
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA267791207R00000X
MARN267791207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA349401Medicare UPIN