Healthcare Provider Details

I. General information

NPI: 1861474835
Provider Name (Legal Business Name): GREGORY HEATON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 WILSON CREEK RD
LAWRENCEBURG IN
47025-2751
US

IV. Provider business mailing address

PO BOX 2
MILTON KY
40045-0002
US

V. Phone/Fax

Practice location:
  • Phone: 812-537-1010
  • Fax:
Mailing address:
  • Phone: 800-288-8325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number22819
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number01032597
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: