Provider Demographics
NPI:1861463689
Name:HEATON, RODNEY GLEN (DO)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:GLEN
Last Name:HEATON
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 1:8467 WISE RIVER ROAD
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803
Mailing Address - Country:US
Mailing Address - Phone:406-491-3792
Mailing Address - Fax:
Practice Address - Street 1:2827 FORT MISSOULA ROAD
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804
Practice Address - Country:US
Practice Address - Phone:406-728-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT10343207Q00000X
AZ3810207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTH90486Medicare UPIN