Provider Demographics
NPI:1083824528
Name:HEITMILLER, DWAYNE R (MD)
Entity Type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:R
Last Name:HEITMILLER
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 1:800 E 28TH ST STE 600
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-3723
Mailing Address - Country:US
Mailing Address - Phone:612-863-5327
Mailing Address - Fax:
Practice Address - Street 1:800 E 28TH ST STE 600
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3723
Practice Address - Country:US
Practice Address - Phone:612-863-5327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN625362084P0015X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI001341802Medicare PIN