Provider Demographics
NPI:1619256013
Name:HEIDEMAN, ELIZABETH RENEE (OD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:RENEE
Last Name:HEIDEMAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 W MORTON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-2623
Mailing Address - Country:US
Mailing Address - Phone:309-693-9540
Mailing Address - Fax:309-693-9542
Practice Address - Street 1:2000 W MORTON AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-2623
Practice Address - Country:US
Practice Address - Phone:217-245-6814
Practice Address - Fax:217-245-0375
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010500152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist