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NPI Code Detail

MEDICARE: DR. ELIZABETH RENEE HEIDEMAN O.D.

MEDICARE: DR. ELIZABETH RENEE HEIDEMAN O.D.
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
1152W00000XOptometrist046.010500IL

General Provider Information

NPI Number : 1619256013
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. ELIZABETH RENEE HEIDEMAN O.D.
Provider Business Mailing Address
First Line : 2000 W MORTON AVE
Second Line :
City : JACKSONVILLE
State : IL
Zip : 62650-2623
Country : US
Telephone Number : 309-693-9540
Fax Number : 309-693-9542
Provider Business Practice Location Address
First Line : 2000 W MORTON AVE
Second Line :
City : JACKSONVILLE
State : IL
Zip : 62650-2623
Country : US
Telephone Number : 217-245-6814
Fax Number : 217-245-0375
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/16/2011
Last Update Date : 07/21/2022

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