Provider Demographics
NPI:1760583140
Name:HEATH, IAN JAMES (MD, CM)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:JAMES
Last Name:HEATH
Suffix:
Gender:M
Credentials:MD, CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MARSH ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-4752
Mailing Address - Country:US
Mailing Address - Phone:507-385-6337
Mailing Address - Fax:507-385-6497
Practice Address - Street 1:1025 MARSH ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-4752
Practice Address - Country:US
Practice Address - Phone:507-385-6337
Practice Address - Fax:507-385-6497
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN396432084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN33G31HEOtherBLUE CROSS / BLUE SHIELD
MN171627100Medicaid
MN080009396Medicare ID - Type UnspecifiedMPIN # (MEDICARE PART B)
MNH24519Medicare UPIN