Provider Demographics
NPI:1184701344
Name:HEINTZELMAN, KEVIN A (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:A
Last Name:HEINTZELMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 23996
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225
Mailing Address - Country:US
Mailing Address - Phone:601-206-6100
Mailing Address - Fax:601-206-6052
Practice Address - Street 1:1200 N STATE ST
Practice Address - Street 2:SUITE 480
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2001
Practice Address - Country:US
Practice Address - Phone:601-352-2273
Practice Address - Fax:601-714-3415
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY224633207R00000X
MS20864207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02272493Medicaid
MS03658704Medicaid
NYH28918Medicare UPIN
NY02272493Medicaid
MS302I117970Medicare PIN