Healthcare Provider Details

I. General information

NPI: 1679928055
Provider Name (Legal Business Name): MARK HEINO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 MDG / RAF LAKENHEATH UNIT 5115
APO AE
09461
US

IV. Provider business mailing address

48 MDG / RAF LAKENHEATH UNIT 5115
APO AE
09461
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-7028
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD468386
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: