Provider Demographics
NPI:1265535058
Name:HEINEN, PETER JAMES (OD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:JAMES
Last Name:HEINEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14673 78TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311
Mailing Address - Country:US
Mailing Address - Phone:763-416-4806
Mailing Address - Fax:
Practice Address - Street 1:8000 LAKELAND AVE N
Practice Address - Street 2:WALMART VISION CENTER
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55445
Practice Address - Country:US
Practice Address - Phone:763-425-4890
Practice Address - Fax:763-424-2787
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN2403152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
22 00055OtherMEDICA
22 00055OtherMEDICA
U34240Medicare UPIN