Provider Demographics
NPI:1346415544
Name:HEIN, JEROME J (ABO/FNAO)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:J
Last Name:HEIN
Suffix:
Gender:M
Credentials:ABO/FNAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-2225
Mailing Address - Country:US
Mailing Address - Phone:608-647-7369
Mailing Address - Fax:
Practice Address - Street 1:132 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-2225
Practice Address - Country:US
Practice Address - Phone:608-647-7369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI03945156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38455200Medicaid