Provider Demographics
NPI:1205918620
Name:HEINER, CRAIG D (MD)
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:D
Last Name:HEINER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:D
Other - Middle Name:CRAIG
Other - Last Name:HEINER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:240 EAST MAIN
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440
Mailing Address - Country:US
Mailing Address - Phone:208-356-8808
Mailing Address - Fax:208-356-8810
Practice Address - Street 1:240 EAST MAIN
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-356-8808
Practice Address - Fax:208-356-8810
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4318207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0027111Medicaid
ID000010003449OtherBLUE SHIELD OF IDAHO
IDDW417OtherBLUE CROSS OF IDAHO
1114357Medicare ID - Type Unspecified
IDDW417OtherBLUE CROSS OF IDAHO