Provider Demographics
NPI:1801818901
Name:HECKENLIVELY, JOHN ROBERT (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:HECKENLIVELY
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 1:3621 S STATE
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1000 WALL ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-1912
Practice Address - Country:US
Practice Address - Phone:734-764-4190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27232207W00000X
MI4301082763207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4572506Medicaid
CA00G272320OtherMEDICAL PPIN #
MI0H16098150Medicare ID - Type Unspecified
CA00G272320OtherMEDICAL PPIN #
CAWG27232EMedicare ID - Type UnspecifiedPPIN #
MI4572506Medicaid