Healthcare Provider Details

I. General information

NPI: 1306077995
Provider Name (Legal Business Name): DOUGLAS HEATON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2009
Last Update Date: 12/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3917 BROADWAY ST
MOUNT VERNON IL
62864-2205
US

IV. Provider business mailing address

5000 CHESHIRE PKWY N
PLYMOUTH MN
55446-4103
US

V. Phone/Fax

Practice location:
  • Phone: 618-242-1120
  • Fax: 618-242-4171
Mailing address:
  • Phone: 888-333-9152
  • Fax: 763-268-4240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2627
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: