Provider Demographics
NPI:1710097068
Name:HEINER, JARED G (MD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:G
Last Name:HEINER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JARED
Other - Middle Name:
Other - Last Name:HEINER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3085 E MAGIC VIEW DR STE 140
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3745
Mailing Address - Country:US
Mailing Address - Phone:208-229-9009
Mailing Address - Fax:208-229-9010
Practice Address - Street 1:3085 E MAGIC VIEW DR STE 140
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3745
Practice Address - Country:US
Practice Address - Phone:208-229-9009
Practice Address - Fax:208-229-9010
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTL3798208800000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000881Medicare PIN