Provider Demographics
NPI:1992778153
Name:HEACOCK, JAMES K (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:K
Last Name:HEACOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:523 PRINCETON AVE
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-4827
Mailing Address - Country:US
Mailing Address - Phone:732-295-2825
Mailing Address - Fax:732-263-9470
Practice Address - Street 1:1640 HIGHWAY 88
Practice Address - Street 2:SUITE 203
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3036
Practice Address - Country:US
Practice Address - Phone:732-458-7777
Practice Address - Fax:732-263-9470
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA03492800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1K8145OtherHEALTHNET
NJ110172482OtherRAILROAD MEDICARE
NJ223360408-010OtherQUALCARE
NJP1043622OtherOXFORD
NJ4745809Medicaid
NJE61855Medicare UPIN
NJ460664Medicare ID - Type Unspecified