Healthcare Provider Details

I. General information

NPI: 1821087636
Provider Name (Legal Business Name): JEFFREY W. HEITKAMP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 W INTERSTATE 20 UNIT G10
ARLINGTON TX
76017-5871
US

IV. Provider business mailing address

PO BOX 152679
ARLINGTON TX
76015-8679
US

V. Phone/Fax

Practice location:
  • Phone: 817-274-4593
  • Fax: 817-274-4098
Mailing address:
  • Phone: 817-274-4593
  • Fax: 817-274-4098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberF4064
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: