Provider Demographics
NPI:1053628172
Name:HEFFNER, JEREMY JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:JAMES
Last Name:HEFFNER
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 1:1001 BELLEFONTAINE AVE
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-2800
Mailing Address - Country:US
Mailing Address - Phone:419-998-4575
Mailing Address - Fax:419-998-4586
Practice Address - Street 1:1003 BELLEFONTAINE AVE
Practice Address - Street 2:SUITE 125
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-2868
Practice Address - Country:US
Practice Address - Phone:419-998-8207
Practice Address - Fax:419-998-8216
Is Sole Proprietor?:No
Enumeration Date:2010-09-10
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301098147208600000X, 2086S0102X
OH57.012489208600000X
OH35.1206642086S0102X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0085017Medicaid
OH0085017Medicaid