Provider Demographics
NPI:1902062219
Name:HEASER, AMITA (MD)
Entity Type:Individual
Prefix:
First Name:AMITA
Middle Name:
Last Name:HEASER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMITA
Other - Middle Name:
Other - Last Name:MUKHERJEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD,
Mailing Address - Street 1:PO BOX 17025
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-7025
Mailing Address - Country:US
Mailing Address - Phone:479-274-2000
Mailing Address - Fax:479-274-2194
Practice Address - Street 1:6801 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4067
Practice Address - Country:US
Practice Address - Phone:479-274-4100
Practice Address - Fax:479-274-4199
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-127885207R00000X
IL125054221207R00000X
ARE9240207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5BA25OtherARKANSAS BLUECROSS BLUE SHIELD
IL036127885Medicaid
IL04515143OtherBCBS#
IL036127885Medicaid
AR5BA25OtherARKANSAS BLUECROSS BLUE SHIELD
AR0384730009Medicare NSC
IL390362Medicare PIN
AR426022YUE2Medicare Oscar/Certification
IL04515143OtherBCBS#