Provider Demographics
NPI:1629398912
Name:HEISE, CRAIG WILLIAM JR (MD)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:WILLIAM
Last Name:HEISE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1300 N 12TH ST
Mailing Address - Street 2:SUITE 605
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2848
Mailing Address - Country:US
Mailing Address - Phone:602-839-2668
Mailing Address - Fax:602-839-2067
Practice Address - Street 1:1300 N 12TH ST
Practice Address - Street 2:SUITE 605
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2848
Practice Address - Country:US
Practice Address - Phone:602-839-2668
Practice Address - Fax:602-839-2067
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ45475207PT0002X, 2083A0300X, 207Q00000X
ORMD221429207PT0002X, 2083A0300X
TXU9545207PT0002X, 2083A0300X
FLME165028207PT0002X, 2083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine