Provider Demographics
NPI:1467474569
Name:HEATON, KEVIN T (DO)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:T
Last Name:HEATON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2200 BRYANT WILLIAMS DRIVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-1120
Mailing Address - Country:US
Mailing Address - Phone:541-884-7746
Mailing Address - Fax:541-884-0848
Practice Address - Street 1:2200 BRYANT WILLIAMS DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1120
Practice Address - Country:US
Practice Address - Phone:541-884-7746
Practice Address - Fax:541-884-0848
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO22887207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR200046213OtherRAILROAD MEDICARE
OR4604977397601OtherTRICARE
OR831170000OtherBLUE CROSS
CAXPY195175OtherMEDI-CAL
OR287483Medicaid
CAXPY195175OtherMEDI-CAL
ORBH5000156OtherDEA
OR831170000OtherBLUE CROSS
OR4665480001Medicare NSC