Provider Demographics
NPI:1356495444
Name:HEINZL, GLEN JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:JOSEPH
Last Name:HEINZL
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:N11015 19TH AVE.
Mailing Address - Street 2:P.O. BOX 499
Mailing Address - City:NECEDAH
Mailing Address - State:WI
Mailing Address - Zip Code:54646
Mailing Address - Country:US
Mailing Address - Phone:608-565-7771
Mailing Address - Fax:
Practice Address - Street 1:2000 PROGRESS DRIVE
Practice Address - Street 2:
Practice Address - City:NEW LISBON
Practice Address - State:WI
Practice Address - Zip Code:53950-2000
Practice Address - Country:US
Practice Address - Phone:608-562-6400
Practice Address - Fax:608-562-7382
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22801207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B53517Medicare UPIN