Healthcare Provider Details

I. General information

NPI: 1770907867
Provider Name (Legal Business Name): ANTHONY JAMES HEIDT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2014
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2154 COMMONS PKWY
OKEMOS MI
48864-3986
US

IV. Provider business mailing address

2154 COMMONS PKWY
OKEMOS MI
48864-3986
US

V. Phone/Fax

Practice location:
  • Phone: 517-657-7906
  • Fax: 517-657-7908
Mailing address:
  • Phone: 517-657-7906
  • Fax: 517-657-7908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number5101022939
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0102204454
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: