Provider Demographics
NPI:1790190338
Name:HEIDE, DREW MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:DREW
Middle Name:MICHAEL
Last Name:HEIDE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2635 W DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67213-2605
Mailing Address - Country:US
Mailing Address - Phone:316-942-7496
Mailing Address - Fax:
Practice Address - Street 1:2635 W DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67213-2605
Practice Address - Country:US
Practice Address - Phone:316-942-7496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1981152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist