Provider Demographics
NPI:1467483776
Name:O'HEARN, JAMES J
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:J
Last Name:O'HEARN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-4528
Mailing Address - Country:US
Mailing Address - Phone:218-822-4242
Mailing Address - Fax:218-822-3758
Practice Address - Street 1:2019 S 6TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-4528
Practice Address - Country:US
Practice Address - Phone:218-822-4242
Practice Address - Fax:218-822-3758
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN420152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0120300OtherPREFERRED ONE
MN21G130HOtherBCBS
MN1601238Medicaid
MN1601238Medicaid