Provider Demographics
NPI:1003194739
Name:HEINTZELMAN, JOHN ALEX (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALEX
Last Name:HEINTZELMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 ROYAL BIRKDALE DR STE A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIANA
Mailing Address - State:OH
Mailing Address - Zip Code:44408-8493
Mailing Address - Country:US
Mailing Address - Phone:330-482-9350
Mailing Address - Fax:330-482-2336
Practice Address - Street 1:107 ROYAL BIRKDALE DR STE A
Practice Address - Street 2:
Practice Address - City:COLUMBIANA
Practice Address - State:OH
Practice Address - Zip Code:44408-8493
Practice Address - Country:US
Practice Address - Phone:330-482-9350
Practice Address - Fax:330-482-2336
Is Sole Proprietor?:No
Enumeration Date:2011-07-29
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35123178207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0106485Medicaid
OHH347380OtherMEDICARE PTAN