Provider Demographics
NPI:1629022397
Name:HEINITZ, THOMAS JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JAMES
Last Name:HEINITZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:211 S BOUNDARY AVE
Mailing Address - Street 2:ESSENTIA HEALTH PROCTOR CLINIC
Mailing Address - City:PROCTOR
Mailing Address - State:MN
Mailing Address - Zip Code:55810-2306
Mailing Address - Country:US
Mailing Address - Phone:218-576-0200
Mailing Address - Fax:218-624-7323
Practice Address - Street 1:211 S BOUNDARY AVE
Practice Address - Street 2:ESSENTIA HEALTH PROCTOR CLINIC
Practice Address - City:PROCTOR
Practice Address - State:MN
Practice Address - Zip Code:55810-2306
Practice Address - Country:US
Practice Address - Phone:218-576-0200
Practice Address - Fax:218-624-7323
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN41634207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1629022397Medicaid
WI1629022397Medicaid
MN1629022397Medicaid
MN080020644Medicare PIN
MN1629022397Medicaid
WI1629022397Medicaid