MEDICARE: JOSEPH DIETRICH HEYNE MD

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	208600000X	Surgery Physician	M9354	TX

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
2	P00945947	OTHER	TX	RAILROAD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710146568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH DIETRICH HEYNE MD

Provider Business Mailing Address
First Line	:	PO BOX 961205
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76161-1205
Country	:	US
Telephone Number	:	817-740-8400
Fax Number	:	817-250-5485

Provider Business Practice Location Address
First Line	:	1250 8TH AVENUE
Second Line	:	SUITE 120
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4156
Country	:	US
Telephone Number	:	817-923-6900
Fax Number	:	817-923-6903

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

Provider Enumeration Date	:	06/06/2008
Last Update Date	:	09/30/2011

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Directions to “ JOSEPH DIETRICH HEYNE MD” Practice Location

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