Provider Demographics
NPI:1861594251
Name:HEINEN, ROBERT DELANO (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DELANO
Last Name:HEINEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 HOFFMANN DR
Mailing Address - Street 2:BETHESDA LUTHERAN HOMES AND SERVICES
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094
Mailing Address - Country:US
Mailing Address - Phone:920-262-6517
Mailing Address - Fax:920-206-7704
Practice Address - Street 1:700 HOFFMANN DR
Practice Address - Street 2:BETHESDA LUTHERAN HOMES AND SERVICES
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094
Practice Address - Country:US
Practice Address - Phone:920-261-3050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15267020208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30992200Medicaid
WI30992200Medicaid