Provider Demographics
NPI:1871869172
Name:HEINZ, BLAKE ANTHONY (DO)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:ANTHONY
Last Name:HEINZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57402-1460
Mailing Address - Country:US
Mailing Address - Phone:605-622-2857
Mailing Address - Fax:605-622-2859
Practice Address - Street 1:815 1ST AVE SE
Practice Address - Street 2:SUITE 104
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4602
Practice Address - Country:US
Practice Address - Phone:605-622-5458
Practice Address - Fax:605-622-5473
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SD9584207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program