Provider Demographics
NPI:1427051390
Name:HEAVNER, ROBERT RANDAL (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:RANDAL
Last Name:HEAVNER
Suffix:
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 1:1212 GARFIELD AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-3247
Mailing Address - Country:US
Mailing Address - Phone:304-865-3611
Mailing Address - Fax:304-577-2169
Practice Address - Street 1:1212 GARFIELD AVE STE 202
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-3247
Practice Address - Country:US
Practice Address - Phone:304-865-3611
Practice Address - Fax:302-577-2169
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.058410207Q00000X
WV15128207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0815158Medicaid
WV0052632000Medicaid
WVE19476Medicare UPIN
WV0637275Medicare PIN
OH4199331Medicare PIN