Provider Demographics
NPI:1588605059
Name:HEATON, GREGORY D (OD PA)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:D
Last Name:HEATON
Suffix:
Gender:M
Credentials:OD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25
Mailing Address - Street 2:
Mailing Address - City:JAY
Mailing Address - State:FL
Mailing Address - Zip Code:32565
Mailing Address - Country:US
Mailing Address - Phone:850-675-0625
Mailing Address - Fax:850-675-3921
Practice Address - Street 1:14088 ALABAMA ST
Practice Address - Street 2:
Practice Address - City:JAY
Practice Address - State:FL
Practice Address - Zip Code:32565
Practice Address - Country:US
Practice Address - Phone:850-675-0625
Practice Address - Fax:850-675-3921
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3531152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621048100Medicaid
FL621048100Medicaid
FL20947ZMedicare PIN