Provider Demographics
NPI:1528268737
Name:HEYWOOD, MARK WILLIAMS (DC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:WILLIAMS
Last Name:HEYWOOD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 747
Mailing Address - Street 2:522 E PINE ST
Mailing Address - City:BOURBON
Mailing Address - State:MO
Mailing Address - Zip Code:65441
Mailing Address - Country:US
Mailing Address - Phone:573-732-5424
Mailing Address - Fax:573-732-5424
Practice Address - Street 1:522 E PINE ST
Practice Address - Street 2:
Practice Address - City:BOURBON
Practice Address - State:MO
Practice Address - Zip Code:65441
Practice Address - Country:US
Practice Address - Phone:573-732-5424
Practice Address - Fax:573-732-5424
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO04011111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
350025032OtherMCRR
MO756822904Medicaid
000030704Medicare ID - Type Unspecified
MHEYW441Medicare UPIN