Provider Demographics
NPI:1548263635
Name:HEYDEMANN, JACOB SAMUEL (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:SAMUEL
Last Name:HEYDEMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1300 MURCHISON DR
Mailing Address - Street 2:STE 310
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-4851
Mailing Address - Country:US
Mailing Address - Phone:915-838-3888
Mailing Address - Fax:915-838-3889
Practice Address - Street 1:1300 MURCHISON DR
Practice Address - Street 2:STE 310
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-4851
Practice Address - Country:US
Practice Address - Phone:915-838-3888
Practice Address - Fax:915-838-3889
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2013-03-04
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-21
Provider Licenses
StateLicense IDTaxonomies
TXF4077207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXX99115Medicare UPIN