Basic Information
| Provider Information | |||||||||
| NPI: | 1285096636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEAVNER | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | GREGORY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 RIDGELY AVE STE 222 | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214011073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102668049 | ||||||||
| FaxNumber: | 4102668054 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 RIDGELY AVE STE 222 | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214011073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102668049 | ||||||||
| FaxNumber: | 4102668054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2016 | ||||||||
| LastUpdateDate: | 08/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MT211746 | PA | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.