Provider Demographics
NPI:1962447961
Name:HEINEN, GREGORY THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:THOMAS
Last Name:HEINEN
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 1:301W HUNTINGTON DR 617
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-1518
Mailing Address - Country:US
Mailing Address - Phone:626-574-9745
Mailing Address - Fax:626-574-8741
Practice Address - Street 1:301W HUNTINGTON DR 617
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-1518
Practice Address - Country:US
Practice Address - Phone:626-574-9745
Practice Address - Fax:626-574-8741
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG081061207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ75817ZMedicaid
CAZZZ75817ZMedicaid
G73426Medicare UPIN
CAW15819Medicare PIN
CAZZZ23524ZMedicare PIN