Provider Demographics
NPI:1083886840
Name:BRIAN W HEATON MD PC
Entity Type:Organization
Organization Name:BRIAN W HEATON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:HEATON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:807-387-4550
Mailing Address - Street 1:4403 HARRISON BLVD
Mailing Address - Street 2:SUITE 4400
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3271
Mailing Address - Country:US
Mailing Address - Phone:807-387-4550
Mailing Address - Fax:801-387-4565
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:SUITE 4400
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-4550
Practice Address - Fax:801-387-4565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT181028-1205208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528908750009Medicaid
UTF60970Medicare UPIN
UT000010836Medicare PIN