1669437968 NPI number — DR. JON DAVID HEAVERLO O.D.

Table of content: MICHAEL PIRO PHARMACIST (NPI 1437629615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669437968 NPI number — DR. JON DAVID HEAVERLO O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEAVERLO
Provider First Name:
JON
Provider Middle Name:
DAVID
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1669437968
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
915 N 5TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARITON
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50049-1238
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-774-7507
Provider Business Mailing Address Fax Number:
641-774-0466

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
131 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARITON
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50049-1270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-774-7507
Provider Business Practice Location Address Fax Number:
641-774-0466
Provider Enumeration Date:
04/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  02187 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 26830 . This is a "BCBS OSCEOLA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0277610001 . This is a "CMERC OVC" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0277610002 . This is a "DMERC CVC" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 26834 . This is a "BCBS CHARITON" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0277610004 . This is a "DMERC OTT" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 6219121 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5219121 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 821921 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 34213 . This is a "BCBS OTTUMWA" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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