Provider Demographics
NPI:1972070191
Name:HEFFINGTON, BRYCE RANDAL (OD)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:RANDAL
Last Name:HEFFINGTON
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:PO BOX 774
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-0774
Mailing Address - Country:US
Mailing Address - Phone:417-869-3937
Mailing Address - Fax:417-869-0281
Practice Address - Street 1:1350 E WOODHURST DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-4281
Practice Address - Country:US
Practice Address - Phone:417-882-3937
Practice Address - Fax:417-887-8551
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018038605152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty