Provider Demographics
NPI:1710103239
Name:HEYNEKAMP, JOHANNES JACOBUS (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHANNES
Middle Name:JACOBUS
Last Name:HEYNEKAMP
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 1:200 NEEL AVE
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801
Mailing Address - Country:US
Mailing Address - Phone:575-835-2940
Mailing Address - Fax:575-835-2216
Practice Address - Street 1:200 NEEL AVE
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801
Practice Address - Country:US
Practice Address - Phone:575-835-2940
Practice Address - Fax:575-835-2216
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM79-179207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00063578Medicaid
NM00063578Medicaid
NMNMAAA2772Medicare UPIN