Provider Demographics
NPI:1992792469
Name:HEINER, ADAM (OD)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:
Last Name:HEINER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3541 W BAVARIA ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6318
Mailing Address - Country:US
Mailing Address - Phone:208-939-5005
Mailing Address - Fax:208-939-2496
Practice Address - Street 1:3541 W BAVARIA ST
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6318
Practice Address - Country:US
Practice Address - Phone:208-939-5005
Practice Address - Fax:208-939-2496
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP 1041152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806965200Medicaid