Provider Demographics
NPI:1912903691
Name:HEIDENRY, ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:HEIDENRY
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 1:6850 HOHMAN AVE
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:IN
Mailing Address - Zip Code:46324-1410
Mailing Address - Country:US
Mailing Address - Phone:219-931-7509
Mailing Address - Fax:
Practice Address - Street 1:17850 KEDZIE AVE
Practice Address - Street 2:SUITE 3500
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2058
Practice Address - Country:US
Practice Address - Phone:708-799-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036048186207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036048186Medicaid
D12516Medicare UPIN
IL036048186Medicaid