Provider Demographics
NPI:1346298742
Name:HEAVRIN, JOHN SLOAN I (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:SLOAN
Last Name:HEAVRIN
Suffix:I
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:HEAVRIN
Other - Suffix:I
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1335 PHAY AVE STE B
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-2349
Mailing Address - Country:US
Mailing Address - Phone:719-285-2735
Mailing Address - Fax:719-285-2915
Practice Address - Street 1:1335 PHAY AVE STE B
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2349
Practice Address - Country:US
Practice Address - Phone:719-285-2735
Practice Address - Fax:719-285-2915
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO24475207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01244755Medicaid
CO160057345OtherRR MEDICARE PIN
CO160057345OtherRR MEDICARE PIN
CO01244755Medicaid