Provider Demographics
NPI:1871592642
Name:HELLER, HENRY M (MD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:M
Last Name:HELLER
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 1:1800 E 3RD AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-5016
Mailing Address - Country:US
Mailing Address - Phone:970-247-0777
Mailing Address - Fax:970-247-0902
Practice Address - Street 1:1800 E 3RD AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-5016
Practice Address - Country:US
Practice Address - Phone:970-247-0777
Practice Address - Fax:970-247-0902
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO22830207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCG3935OtherRAILROAD MEDICARE
COCG8308OtherMEDICARE ID-TYPE UNSPECIF
CO01228303Medicaid
NMU0386Medicaid
CO0306020001Medicare NSC
COG8328Medicare ID - Type Unspecified
CO01228303Medicaid
COCG8308Medicare PIN