MEDICARE: DR. MICHAEL S HEIDISH OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4562/T1305	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306843727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL S HEIDISH OD

Provider Business Mailing Address
First Line	:	3384 STATE ROUTE 752
Second Line	:
City	:	ASHVILLE
State	:	OH
Zip	:	43103-9685
Country	:	US
Telephone Number	:	740-983-6171
Fax Number	:	740-983-6587

Provider Business Practice Location Address
First Line	:	3384 STATE ROUTE 752
Second Line	:
City	:	ASHVILLE
State	:	OH
Zip	:	43103-9685
Country	:	US
Telephone Number	:	740-983-6171
Fax Number	:	740-983-6587

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	10/09/2012

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