Provider Demographics
NPI:1821174426
Name:HEINZ, BETHANY (OD)
Entity Type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:
Last Name:HEINZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:BETHANY
Other - Middle Name:
Other - Last Name:MCKITTRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:W6330 BIRMINGHAM ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:54942-8806
Mailing Address - Country:US
Mailing Address - Phone:970-776-6537
Mailing Address - Fax:
Practice Address - Street 1:1000 N WESTHILL BLVD
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-5792
Practice Address - Country:US
Practice Address - Phone:920-733-7804
Practice Address - Fax:920-733-7940
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2425152W00000X
WI3213-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COV01064Medicare UPIN