Provider Demographics
NPI:1760501373
Name:HEIST, JON S (DO)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:S
Last Name:HEIST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:361 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-1920
Mailing Address - Country:US
Mailing Address - Phone:856-881-8618
Mailing Address - Fax:856-881-5368
Practice Address - Street 1:361 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GLASSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08028-1920
Practice Address - Country:US
Practice Address - Phone:856-881-8618
Practice Address - Fax:856-881-5368
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05940000207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8091609Medicaid
F81713Medicare UPIN
034286Medicare ID - Type Unspecified