Provider Demographics
NPI:1881047918
Name:HEISTERKAMP, D'LAINE N (OD)
Entity type:Individual
Prefix:
First Name:D'LAINE
Middle Name:N
Last Name:HEISTERKAMP
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:D'LAINE
Other - Middle Name:N
Other - Last Name:PULLIAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1872 NORWOOD DR STE 200
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-7018
Mailing Address - Country:US
Mailing Address - Phone:817-540-6060
Mailing Address - Fax:817-553-7994
Practice Address - Street 1:1872 NORWOOD DR STE 200
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-7018
Practice Address - Country:US
Practice Address - Phone:817-540-6060
Practice Address - Fax:817-553-7994
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8915TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist