1003090556 NPI number — GREGORY D HEATON OD PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003090556 NPI number — GREGORY D HEATON OD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREGORY D HEATON OD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JAY VISION CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003090556
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JAY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32565-0025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-675-0625
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14088 ALABAMA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32565-1036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-675-0625
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KELLEY
Authorized Official First Name:
ANGEL
Authorized Official Middle Name:
Authorized Official Title or Position:
DELEGATED OFFICIAL
Authorized Official Telephone Number:
850-675-0625

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC3531 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 621048100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008698200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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