Provider Demographics
NPI:1033241997
Name:HEINS, GARY DENNIS (LICENSED OPTICIAN)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:DENNIS
Last Name:HEINS
Suffix:
Gender:M
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-1769
Mailing Address - Country:US
Mailing Address - Phone:203-239-6172
Mailing Address - Fax:203-239-0295
Practice Address - Street 1:117 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-1769
Practice Address - Country:US
Practice Address - Phone:203-239-6172
Practice Address - Fax:203-239-0295
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTLO-# 715156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0648180001OtherNSC--NUMBER
CT61-1442432OtherFEDERAL TAX
CT100000715CT-01OtherBLUE CROSS PROVIDER
CT0648180001Medicare NSC