MEDICARE: JONATHAN BARRY HEISTEIN M.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
1	208200000X	Plastic Surgery Physician	L3330	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	108590	OTHER	TX	AMERIGROUP
2	7569341	OTHER	TX	AETNA
3	0007JD	OTHER	TX	BLUE CROSS/BLUE SHIELD
4	158570718	OTHER	TX	PACIFICARE
5	865822	OTHER	TX	USA MANAGED CARE
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972590404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN BARRY HEISTEIN M.D.

Provider Business Mailing Address
First Line	:	800 8TH AVE
Second Line	:	SUITE 240
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2601
Country	:	US
Telephone Number	:	817-820-0000
Fax Number	:	817-820-0097

Provider Business Practice Location Address
First Line	:	800 8TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2619
Country	:	US
Telephone Number	:	817-820-0000
Fax Number	:	817-820-0097

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

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	07/08/2007

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