Provider Demographics
NPI:1184629156
Name:COUCH, HEATHER A (DPM)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:A
Last Name:COUCH
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16841 N. 31ST AVE
Mailing Address - Street 2:STE. 134
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-3051
Mailing Address - Country:US
Mailing Address - Phone:623-322-5001
Mailing Address - Fax:623-322-8996
Practice Address - Street 1:16841 N. 31ST AVE
Practice Address - Street 2:STE. 134
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-3051
Practice Address - Country:US
Practice Address - Phone:623-322-5001
Practice Address - Fax:623-322-8996
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2008-02-26
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
AZ0552213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00208444OtherRAILROAD MEDICARE
AZZ78990OtherMEDICARE ID-PIN
AZZ78990OtherMEDICARE ID-PIN