Provider Demographics
NPI:1548438260
Name:PAUL H HEAVNER
Entity type:Organization
Organization Name:PAUL H HEAVNER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERI
Authorized Official - Middle Name:DENEEN
Authorized Official - Last Name:HEAVNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-834-6400
Mailing Address - Street 1:60 SOUDER ROAD
Mailing Address - Street 2:BRUNSWICK FAMILY VISION CENTER
Mailing Address - City:BRUNSWICK
Mailing Address - State:MD
Mailing Address - Zip Code:21716
Mailing Address - Country:US
Mailing Address - Phone:301-834-6400
Mailing Address - Fax:301-834-7585
Practice Address - Street 1:60 SOUDER ROAD
Practice Address - Street 2:BRUNSWICK FAMILY VISION CENTER
Practice Address - City:BRUNSWICK
Practice Address - State:MD
Practice Address - Zip Code:21716
Practice Address - Country:US
Practice Address - Phone:301-834-6400
Practice Address - Fax:301-834-7585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1121152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0711690001Medicare NSC