Provider Demographics
NPI:1336596386
Name:HEINEMANN, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:HEINEMANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DANN
Other - Middle Name:
Other - Last Name:HEINEMANN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 161941
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32716-1941
Mailing Address - Country:US
Mailing Address - Phone:407-595-5457
Mailing Address - Fax:407-772-0378
Practice Address - Street 1:2401 OAK DR
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-4745
Practice Address - Country:US
Practice Address - Phone:407-595-5457
Practice Address - Fax:407-772-0378
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCGC058989171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691368779Medicaid