Provider Demographics
NPI:1861484263
Name:HEYDE, RAYMOND R (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:R
Last Name:HEYDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 NE SAINT MARK CT
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3717
Mailing Address - Country:US
Mailing Address - Phone:309-674-1234
Mailing Address - Fax:309-674-6422
Practice Address - Street 1:400 NE SAINT MARK CT
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3717
Practice Address - Country:US
Practice Address - Phone:309-674-1234
Practice Address - Fax:309-674-6422
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075507207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036075507Medicaid
D16702Medicare UPIN
786980Medicare PIN