Provider Demographics
NPI:1700998010
Name:BEVERLY A HEINKING, D.O.
Entity Type:Organization
Organization Name:BEVERLY A HEINKING, D.O.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HEINKING
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:386-362-1014
Mailing Address - Street 1:300 PINEWOOD DR SW
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32064-4029
Mailing Address - Country:US
Mailing Address - Phone:386-362-1014
Mailing Address - Fax:386-362-5076
Practice Address - Street 1:300 PINEWOOD DR SW
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-4029
Practice Address - Country:US
Practice Address - Phone:386-362-1014
Practice Address - Fax:386-362-5076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5866207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL051350402Medicaid
FL80431DMedicare ID - Type Unspecified
FL051350402Medicaid
FLQ0228Medicare PIN