Provider Demographics
NPI:1740353465
Name:HEISE, DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:HEISE
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 1:735 DUNLAWTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-9226
Mailing Address - Country:US
Mailing Address - Phone:888-808-0488
Mailing Address - Fax:386-872-4232
Practice Address - Street 1:735 DUNLAWTON AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-9226
Practice Address - Country:US
Practice Address - Phone:888-808-0488
Practice Address - Fax:386-872-4232
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0083299207Q00000X
FLME83299208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262487700Medicaid
FLME83299OtherSTATE MEDICAL LICENSE
FL06216ZMedicare PIN
FLME83299OtherSTATE MEDICAL LICENSE