Provider Demographics
NPI:1669437968
Name:HEAVERLO, JON DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:DAVID
Last Name:HEAVERLO
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 1:915 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:CHARITON
Mailing Address - State:IA
Mailing Address - Zip Code:50049-1238
Mailing Address - Country:US
Mailing Address - Phone:641-774-7507
Mailing Address - Fax:641-774-0466
Practice Address - Street 1:131 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHARITON
Practice Address - State:IA
Practice Address - Zip Code:50049-1270
Practice Address - Country:US
Practice Address - Phone:641-774-7507
Practice Address - Fax:641-774-0466
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02187152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA26830OtherBCBS OSCEOLA
IA0277610001OtherCMERC OVC
IA0277610002OtherDMERC CVC
IA26834OtherBCBS CHARITON
IA0277610004OtherDMERC OTT
IA6219121Medicaid
IA5219121Medicaid
IA821921Medicaid
IA34213OtherBCBS OTTUMWA
IA0277610001OtherCMERC OVC
IA0277610004OtherDMERC OTT
IA821921Medicaid