Basic Information
| Provider Information | |||||||||
| NPI: | 1710146568 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEYNE | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | DIETRICH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 961205 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761611205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177408400 | ||||||||
| FaxNumber: | 8172505485 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 8TH AVENUE | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179236900 | ||||||||
| FaxNumber: | 8179236903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2008 | ||||||||
| LastUpdateDate: | 09/30/2011 | ||||||||
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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 | 208600000X | M9354 | TX | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 204023002 | 01 | TX | MEDICAID CSHCN | OTHER | P00945947 | 01 | TX | RAILROAD | OTHER | 204023001 | 05 | TX | MEDICAID |