Provider Demographics
NPI:1194838375
Name:HEITZMAN, JON E (OD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:E
Last Name:HEITZMAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 TRAIL CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-8352
Mailing Address - Country:US
Mailing Address - Phone:208-734-0036
Mailing Address - Fax:
Practice Address - Street 1:2680 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-6128
Practice Address - Country:US
Practice Address - Phone:208-324-4333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-495152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8041644Medicaid
IDT44341Medicare UPIN
ID8041644Medicaid