Basic Information
| Provider Information | |||||||||
| NPI: | 1629067962 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEATON | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 21228 | ||||||||
| Address2: | DEPT. 18 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185798204 | ||||||||
| FaxNumber: | 9185798200 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 S UTICA AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741044012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185798215 | ||||||||
| FaxNumber: | 9185798204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 02/15/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 18768 | OK | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 920001079 | 01 | OK | RAILROAD MEDICARE | OTHER | 100056850A | 05 | OK | MEDICAID |