Provider Demographics
NPI:1255583225
Name:HEINGARTEN, KEVIN CHARLES (IDC)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:CHARLES
Last Name:HEINGARTEN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 SPRING LEAF LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-8830
Mailing Address - Country:US
Mailing Address - Phone:910-451-4396
Mailing Address - Fax:
Practice Address - Street 1:143 SPRING LEAF LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-8830
Practice Address - Country:US
Practice Address - Phone:910-451-4396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman