Provider Demographics
NPI:1548212590
Name:HANISCH, HEIDI (OD)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:HANISCH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:
Other - Last Name:HANISCH-DOTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 30128
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-1228
Mailing Address - Country:US
Mailing Address - Phone:402-898-3232
Mailing Address - Fax:402-898-3234
Practice Address - Street 1:9239 W CENTER RD
Practice Address - Street 2:SUITE 103
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-1900
Practice Address - Country:US
Practice Address - Phone:402-898-3232
Practice Address - Fax:402-898-3234
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1033152W00000X
IA02209152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA18429Medicare ID - Type Unspecified
U44313Medicare UPIN