Provider Demographics
NPI:1902070253
Name:SAMPLE, HEATHER (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:SHEETS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2895 TUSCANIA LN
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-2385
Mailing Address - Country:US
Mailing Address - Phone:806-518-8296
Mailing Address - Fax:
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-0591
Practice Address - Country:US
Practice Address - Phone:409-772-1221
Practice Address - Fax:409-772-1224
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXN7581207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXN7581OtherTEXAS LICENSE NUMBER
TXN7581OtherTEXAS LICENSE NUMBER