Provider Demographics
NPI:1659388866
Name:HEINEN, DAVID P (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:HEINEN
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 1:919 HIDDEN RDG
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-2609
Practice Address - Street 1:1960 TYBEE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4173
Practice Address - Country:US
Practice Address - Phone:337-421-0090
Practice Address - Fax:337-421-0015
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.200386207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1053368Medicaid
LA1053368Medicaid
LA4J901BC11Medicare PIN
P00417433Medicare PIN
P00417433Medicare PIN