Provider Demographics
NPI:1023022324
Name:HEACOCK, DONALD GARY (PT)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:GARY
Last Name:HEACOCK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-258-2714
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:7310 RITCHIE HWY
Practice Address - Street 2:SUITE 500
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3065
Practice Address - Country:US
Practice Address - Phone:410-766-4435
Practice Address - Fax:410-766-4437
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15332225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD756LN288OtherRAILROAD MEDICARE
MD147433401OtherACS / US DEPT OF LABOR
MD1359660OtherAETNA USHEALTHCARE
MD145799600OtherOWCP/DEPARTMENT OF LABOR
MD1784629OtherUNITED HEALTHCARE
MD521200786OtherUNITED HEALTH CARE
MD521200786OtherUNITED HEALTH CARE