Provider Demographics
NPI:1497246862
Name:HEAVIN, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:HEAVIN
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 1:1100 SOUTHFIELD DR STE 1370
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-4300
Mailing Address - Country:US
Mailing Address - Phone:317-837-5566
Mailing Address - Fax:317-837-5567
Practice Address - Street 1:1000 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IN
Practice Address - Zip Code:46122-1948
Practice Address - Country:US
Practice Address - Phone:317-745-4451
Practice Address - Fax:317-718-6740
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-22
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01033265A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program