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General NPI Number Information
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NPI Number | 1548499882
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Entity Type | Individual
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Provider Name | JUSTIN THOMAS HEINTZ OD
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Gender | Male
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Dates
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Enumeration Date | 07/08/2009
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Last Update Date | 10/29/2024
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Provider Practice Location Address
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Address Line | 524 N STATE ST
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City | SHELLEY
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State | ID
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Zip | 83274
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Country | US
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Telephone | 208-357-5733
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Fax | 208-357-2240
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Provider Business Mailing Address
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Address Line | 524 N STATE ST
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City | SHELLEY
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State | ID
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Zip | 83274
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Country | US
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Telephone | 208-357-5733
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Fax | 208-357-2240
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 100613
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 3307ATI
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License Number State | OR
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