Provider Demographics
NPI:1003090556
Name:GREGORY D HEATON OD PA
Entity Type:Organization
Organization Name:GREGORY D HEATON OD PA
Other - Org Name:JAY VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-675-0625
Mailing Address - Street 1:PO BOX 25
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:FL
Mailing Address - Zip Code:32565-0025
Mailing Address - Country:US
Mailing Address - Phone:850-675-0625
Mailing Address - Fax:
Practice Address - Street 1:14088 ALABAMA ST
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:FL
Practice Address - Zip Code:32565-1036
Practice Address - Country:US
Practice Address - Phone:850-675-0625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3531152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621048100Medicaid
FL5570900001Medicare NSC
FL621048100Medicaid