Provider Demographics
NPI:1548499882
Name:HEINTZ, JUSTIN THOMAS (OD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:THOMAS
Last Name:HEINTZ
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 1:524 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:SHELLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83274
Mailing Address - Country:US
Mailing Address - Phone:208-357-5733
Mailing Address - Fax:208-357-2240
Practice Address - Street 1:524 N STATE ST
Practice Address - Street 2:
Practice Address - City:SHELLEY
Practice Address - State:ID
Practice Address - Zip Code:83274
Practice Address - Country:US
Practice Address - Phone:208-357-5733
Practice Address - Fax:208-357-2240
Is Sole Proprietor?:No
Enumeration Date:2009-07-08
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID100613152W00000X
OR3307ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR153314Medicare PIN