Provider Demographics
NPI:1710146568
Name:HEYNE, JOSEPH DIETRICH (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:DIETRICH
Last Name:HEYNE
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:PO BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8400
Mailing Address - Fax:817-250-5485
Practice Address - Street 1:1250 8TH AVENUE
Practice Address - Street 2:SUITE 120
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4156
Practice Address - Country:US
Practice Address - Phone:817-923-6900
Practice Address - Fax:817-923-6903
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM9354208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX204023002OtherMEDICAID CSHCN
TXP00945947OtherRAILROAD
TX204023001Medicaid