Provider Demographics
NPI:1366753865
Name:HEINER, DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:HEINER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14155 N 83RD AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-5640
Mailing Address - Country:US
Mailing Address - Phone:623-215-0911
Mailing Address - Fax:
Practice Address - Street 1:14155 N 83RD AVE STE 110
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5640
Practice Address - Country:US
Practice Address - Phone:623-215-0911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI14668207N00000X
UT9250806-1205207N00000X
AZ50534207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology