Provider Demographics
NPI:1992720940
Name:HEATH, ROBERT W (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:HEATH
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:MISSOURI STATE UNIVERSITY
Mailing Address - Street 2:901 S NATIONAL AVE
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65897-0001
Mailing Address - Country:US
Mailing Address - Phone:417-836-4000
Mailing Address - Fax:
Practice Address - Street 1:MISSOURI STATE UNIVERSITY
Practice Address - Street 2:901 S NATIONAL AVE
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65897-0001
Practice Address - Country:US
Practice Address - Phone:417-836-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6N81207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E84552Medicare UPIN