Provider Demographics
NPI:1417044231
Name:HEATON, KENNETH JOSEPH (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOSEPH
Last Name:HEATON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2517 NORTH GLEBE ROAD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON,
Mailing Address - State:VA
Mailing Address - Zip Code:22207
Mailing Address - Country:US
Mailing Address - Phone:703-522-8404
Mailing Address - Fax:703-522-2692
Practice Address - Street 1:2517 N GLEBE RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22207-3524
Practice Address - Country:US
Practice Address - Phone:703-522-8404
Practice Address - Fax:703-522-2692
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102037042207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA$$$$$$$$$OtherSSN
VA647375Medicare PIN