Provider Demographics
NPI:1124154315
Name:HEITMEYER, BRYAN J (OD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:J
Last Name:HEITMEYER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8009 S 180TH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98032-1042
Mailing Address - Country:US
Mailing Address - Phone:425-251-9200
Mailing Address - Fax:425-251-9201
Practice Address - Street 1:8009 S 180TH ST STE 104
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-1042
Practice Address - Country:US
Practice Address - Phone:425-251-9200
Practice Address - Fax:425-251-9201
Is Sole Proprietor?:No
Enumeration Date:2007-02-24
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003905152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2188HEOtherREGENCE
WA2730027OtherUNITED HEALTHCARE
WA7364884OtherAETNA
WA226820OtherLABOR & INDUSTRY
WA7364884OtherAETNA
WAG8871715Medicare UPIN