Provider Demographics
NPI:1073733671
Name:KEVIN T HEATON DO PC
Entity Type:Organization
Organization Name:KEVIN T HEATON DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANNETTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GANSBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-274-2902
Mailing Address - Street 1:2200 BRYANT WILLIAMS DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1120
Mailing Address - Country:US
Mailing Address - Phone:541-884-7746
Mailing Address - Fax:541-884-0848
Practice Address - Street 1:2200 BRYANT WILLIAMS DR
Practice Address - Street 2:SUITE 1
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1120
Practice Address - Country:US
Practice Address - Phone:541-884-7746
Practice Address - Fax:541-884-0848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO22887174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287483Medicaid
CAXPY195175OtherMEDICAL
ORDG2430OtherRAIL ROAD MEDICARE
OR4604977397601OtherTRICARE
OR831170000OtherBLUE CROSS
OR831170000OtherBLUE CROSS
ORBH5000156OtherDEA
ORH29022Medicare UPIN
CAXPY195175OtherMEDICAL