Healthcare Provider Details

I. General information

NPI: 1629398912
Provider Name (Legal Business Name): CRAIG WILLIAM HEISE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2010
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N 12TH ST SUITE 605
PHOENIX AZ
85006-2848
US

IV. Provider business mailing address

1300 N 12TH ST SUITE 605
PHOENIX AZ
85006-2848
US

V. Phone/Fax

Practice location:
  • Phone: 602-839-2668
  • Fax: 602-839-2067
Mailing address:
  • Phone: 602-839-2668
  • Fax: 602-839-2067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License Number45475
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License NumberMD221429
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License NumberU9545
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License NumberME165028
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License NumberMD221429
License Number StateOR
# 6
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number45475
License Number StateAZ
# 7
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License NumberME165028
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License NumberU9545
License Number StateTX
# 9
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number45475
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: