Basic Information
| Provider Information | |||||||||
| NPI: | 1275739856 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEINLEN | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 STANTON L YOUNG BLVD STE 3150 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052716900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 825 NE 10TH ST STE 5F | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052718156 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2007 | ||||||||
| LastUpdateDate: | 12/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 25642 | OK | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 200171740B | 05 | OK | MEDICAID |