Provider Demographics
NPI:1629244355
Name:HEATON, BREN A (MD)
Entity Type:Individual
Prefix:DR
First Name:BREN
Middle Name:A
Last Name:HEATON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:6140 W CURTISIAN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-0109
Practice Address - Country:US
Practice Address - Phone:208-367-7090
Practice Address - Fax:208-367-7092
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IDM-11687208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program