Provider Demographics
NPI:1356724892
Name:HEEMSTRA, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HEEMSTRA
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 1:10343 DAWSONS CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1906
Mailing Address - Country:US
Mailing Address - Phone:260-739-6167
Mailing Address - Fax:
Practice Address - Street 1:10343 DAWSONS CREEK BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1906
Practice Address - Country:US
Practice Address - Phone:260-203-9600
Practice Address - Fax:260-739-6167
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301108240207P00000X
IN01079987A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine