Provider Demographics
NPI:1497715718
Name:JACOB S. HEYDEMANN M.D. PA
Entity Type:Organization
Organization Name:JACOB S. HEYDEMANN M.D. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:S
Authorized Official - Last Name:HEYDEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-838-3888
Mailing Address - Street 1:1300 MURCHISON DR
Mailing Address - Street 2:STE 310
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-4842
Mailing Address - Country:US
Mailing Address - Phone:915-838-3888
Mailing Address - Fax:915-838-3889
Practice Address - Street 1:1300 MURCHISON DR
Practice Address - Street 2:STE 310
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-4842
Practice Address - Country:US
Practice Address - Phone:915-838-3888
Practice Address - Fax:915-838-3889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4077207X00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00896VMedicare ID - Type UnspecifiedMEDICARE NUMBER
TXX99115Medicare UPIN