Provider Demographics
NPI:1285990739
Name:HEITHAUS, ROBERT EVANS JR (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EVANS
Last Name:HEITHAUS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 W UNDERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1110
Mailing Address - Country:US
Mailing Address - Phone:321-842-8475
Mailing Address - Fax:407-849-6470
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:100374
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0374
Practice Address - Country:US
Practice Address - Phone:352-265-0291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-10
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1302112085R0202X, 2085R0204X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8Y3IOtherBCBS
FLJK675YOtherMEDICARE PTAN OHRI
FLPS295OtherMEDICARE PTAN OHMG
FL024688800Medicaid