Provider Demographics
NPI:1750367231
Name:HEERSINK, PAUL WILLIAM (OD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:WILLIAM
Last Name:HEERSINK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CHICO CT
Mailing Address - Street 2:SUITE B
Mailing Address - City:MONTE VISTA
Mailing Address - State:CO
Mailing Address - Zip Code:81144-1067
Mailing Address - Country:US
Mailing Address - Phone:719-852-3412
Mailing Address - Fax:719-852-3345
Practice Address - Street 1:101 CHICO CT
Practice Address - Street 2:SUITE B
Practice Address - City:MONTE VISTA
Practice Address - State:CO
Practice Address - Zip Code:81144-1067
Practice Address - Country:US
Practice Address - Phone:719-852-3412
Practice Address - Fax:719-852-3345
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO990152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08009904Medicaid
CO60778Medicare UPIN
CO08009904Medicaid