Provider Demographics
NPI:1073593737
Name:HEINKING, BEVERLY ANN (DO)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:ANN
Last Name:HEINKING
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PINEWOOD DR SW
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064-4029
Mailing Address - Country:US
Mailing Address - Phone:386-362-1014
Mailing Address - Fax:386-362-5076
Practice Address - Street 1:300 PINEWOOD DR SW
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-4029
Practice Address - Country:US
Practice Address - Phone:386-362-1014
Practice Address - Fax:386-362-5076
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5866207Q00000X
MOR9F01207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80431OtherB/C
FL80431OtherB/C
FLC50523Medicare UPIN