Provider Demographics
NPI:1285682542
Name:HEINE, DONALD L (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:L
Last Name:HEINE
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 5205
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88102-5205
Mailing Address - Country:US
Mailing Address - Phone:575-762-2121
Mailing Address - Fax:575-935-2121
Practice Address - Street 1:1600 W 21ST ST
Practice Address - Street 2:SUITE A
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4084
Practice Address - Country:US
Practice Address - Phone:575-762-2121
Practice Address - Fax:575-935-2121
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ5347207RC0000X
NMMD2006-0020207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145439901Medicaid
TX145439901Medicaid
TX00659RMedicare ID - Type Unspecified
NMNMB2034Medicare PIN