Provider Demographics
NPI:1558368258
Name:HESTON, ROBERT MICHEAL (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MICHEAL
Last Name:HESTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 4TH ST SW
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-2752
Mailing Address - Country:US
Mailing Address - Phone:641-423-7555
Mailing Address - Fax:641-423-8291
Practice Address - Street 1:1411 4TH ST SW
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401-2752
Practice Address - Country:US
Practice Address - Phone:641-423-7555
Practice Address - Fax:641-423-8291
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2013-11-13
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
IA01526152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1068759Medicaid
IAI14382Medicare ID - Type Unspecified
IA1068759Medicaid