Provider Demographics
NPI:1881894608
Name:HENINGER, JEFFREY DONALD (OD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DONALD
Last Name:HENINGER
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 1:410 1ST ST E STE A
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-2130
Mailing Address - Country:US
Mailing Address - Phone:406-883-4355
Mailing Address - Fax:406-883-4355
Practice Address - Street 1:410 1ST ST E STE A
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-2130
Practice Address - Country:US
Practice Address - Phone:406-883-4355
Practice Address - Fax:406-883-4355
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT792152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT6136580001Medicare NSC
MT1831382605Medicare NSC