Provider Demographics
NPI:1578864310
Name:DR. PAMELA R. HEIPLE P.A.
Entity type:Organization
Organization Name:DR. PAMELA R. HEIPLE P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:HEIPLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:321-508-0793
Mailing Address - Street 1:1700 W NEW HAVEN AVE
Mailing Address - Street 2:C/O JCPENNEY OPTICAL
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-3919
Mailing Address - Country:US
Mailing Address - Phone:321-727-8807
Mailing Address - Fax:321-676-1541
Practice Address - Street 1:1700 W NEW HAVEN AVE
Practice Address - Street 2:C/O JCPENNEY OPTICAL
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3919
Practice Address - Country:US
Practice Address - Phone:321-727-8807
Practice Address - Fax:321-676-1541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-10
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC002725152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20492ZMedicare UPIN