Provider Demographics
NPI:1245346980
Name:HEINER, DALLIN (OD)
Entity type:Individual
Prefix:DR
First Name:DALLIN
Middle Name:
Last Name:HEINER
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 1:244 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2022
Mailing Address - Country:US
Mailing Address - Phone:208-359-1880
Mailing Address - Fax:208-359-2025
Practice Address - Street 1:244 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2022
Practice Address - Country:US
Practice Address - Phone:208-359-1880
Practice Address - Fax:208-359-2025
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP 100060152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806951300Medicaid
IDV6515OtherBLUE CROSS OF IDAHO
ID000010147628OtherREGENCE BLUE SHIELD OF ID
ID857241OtherDESERET MUTUAL
ID533546001Medicare PIN
IDV01318Medicare UPIN
IDV6515OtherBLUE CROSS OF IDAHO