Provider Demographics
NPI:1164448924
Name:PHILLIPS, HEATHER RENEE (OD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:RENEE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19013 BISCAYNE BLVD
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-2819
Mailing Address - Country:US
Mailing Address - Phone:305-935-5250
Mailing Address - Fax:
Practice Address - Street 1:19013 BISCAYNE BLVD
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-2819
Practice Address - Country:US
Practice Address - Phone:305-935-5250
Practice Address - Fax:305-945-3361
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3730152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620841000Medicaid
FL620841001Medicaid
FLU96029Medicare UPIN
FLU0995BMedicare ID - Type UnspecifiedBISCAYNE BLVD OFFICE
FL620841000Medicaid