Provider Demographics
NPI:1093883613
Name:HEIPLE, PAMELA (OD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:HEIPLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:PAMELA
Other - Middle Name:R
Other - Last Name:HEIPLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:3330 WESTLAND
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7859
Mailing Address - Country:US
Mailing Address - Phone:321-508-0793
Mailing Address - Fax:321-676-1541
Practice Address - Street 1:1700 W NEW HAVEN AVE
Practice Address - Street 2:JCPENNEY OPTICAL
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3919
Practice Address - Country:US
Practice Address - Phone:321-727-8807
Practice Address - Fax:321-676-1541
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC002725152W00000X
TX4813152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20492ZMedicare UPIN
FLEB592AMedicare UPIN