Provider Demographics
NPI:1831270651
Name:HEINE, JOHN PARKER (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:PARKER
Last Name:HEINE
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 1:1999 MOWRY AVE
Mailing Address - Street 2:#2M
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538
Mailing Address - Country:US
Mailing Address - Phone:510-793-3505
Mailing Address - Fax:510-793-4799
Practice Address - Street 1:1999 MOWRY AVE
Practice Address - Street 2:#2M
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538
Practice Address - Country:US
Practice Address - Phone:510-793-3505
Practice Address - Fax:510-793-4799
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24518208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A245180Medicaid
CA00A245180Medicaid
CA00A245180Medicare ID - Type Unspecified