Provider Demographics
NPI:1609245323
Name:HEUCK, WALTER EDWARD
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:EDWARD
Last Name:HEUCK
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 1:15113 W LAS BRIZAS LN
Mailing Address - Street 2:
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-3056
Mailing Address - Country:US
Mailing Address - Phone:602-576-7738
Mailing Address - Fax:
Practice Address - Street 1:15113 W LAS BRIZAS LN
Practice Address - Street 2:
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-3056
Practice Address - Country:US
Practice Address - Phone:602-576-7738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ041253OtherAHCCCS