Provider Demographics
NPI:1225051089
Name:HEATON, KIM T (MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:T
Last Name:HEATON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-840-2020
Mailing Address - Fax:
Practice Address - Street 1:3845 W 4700 S
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84118-3454
Practice Address - Country:US
Practice Address - Phone:801-840-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1702211205207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000059998Medicare PIN
UT005577722Medicare PIN
UT005587613Medicare PIN
UT005789605Medicare PIN
UT005556740Medicare PIN
UT055488115Medicare PIN
UT006985008Medicare PIN
UT005569134Medicare PIN
UT005806022Medicare PIN
UT006986023Medicare PIN
UT005551819Medicare PIN
UT005583304Medicare PIN
UT005586714Medicare PIN
UT005728815Medicare PIN