Basic Information
| Provider Information | |||||||||
| NPI: | 1396734927 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEIKES | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19876 SAINT JOSEPH DR | ||||||||
| Address2: | CENTERVILLE MEDICAL CLINIC | ||||||||
| City: | CENTERVILLE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 525448850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6418568684 | ||||||||
| FaxNumber: | 6418563009 | ||||||||
| Practice Location | |||||||||
| Address1: | 19876 SAINT JOSEPH DR | ||||||||
| Address2: | CENTERVILLE MEDICAL CLINIC | ||||||||
| City: | CENTERVILLE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 525448850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6418568684 | ||||||||
| FaxNumber: | 6418563009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 03/12/2008 | ||||||||
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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 | 207Q00000X | 22165 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4204495 | 05 | IA | MEDICAID | P00002281 | 01 | IA | RR MEDICARE | OTHER |