Provider Demographics
NPI:1013951813
Name:HEISS, JOHN RAYMOND (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RAYMOND
Last Name:HEISS
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 1:1099 MEDICAL CENTER CIR
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-1159
Mailing Address - Country:US
Mailing Address - Phone:270-251-4243
Mailing Address - Fax:270-251-4220
Practice Address - Street 1:1099 MEDICAL CENTER CIR
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-1159
Practice Address - Country:US
Practice Address - Phone:270-251-4243
Practice Address - Fax:270-251-4220
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29028207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYD62347Medicare UPIN
KY0623617Medicare ID - Type Unspecified