Healthcare Provider Details

I. General information

NPI: 1548499882
Provider Name (Legal Business Name): JUSTIN THOMAS HEINTZ OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 S WOODRUFF AVE
IDAHO FALLS ID
83401-5596
US

IV. Provider business mailing address

665 S WOODRUFF AVE
IDAHO FALLS ID
83401-5596
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-4552
  • Fax: 208-524-4559
Mailing address:
  • Phone: 208-524-4552
  • Fax: 208-524-4559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3307ATI
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number100613
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: