Provider Demographics
NPI:1902072705
Name:HEGAZY, HESHAM
Entity Type:Individual
Prefix:
First Name:HESHAM
Middle Name:
Last Name:HEGAZY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S SHORE DR
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-2017
Mailing Address - Country:US
Mailing Address - Phone:475-350-0010
Mailing Address - Fax:574-970-0940
Practice Address - Street 1:150 S SHORE DR
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-2017
Practice Address - Country:US
Practice Address - Phone:475-350-0010
Practice Address - Fax:574-970-0940
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016503225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02242762Medicaid