Basic Information
| Provider Information | |||||||||
| NPI: | 1588664106 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEITHOLD | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7305 JARNIGAN ROAD | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234954349 | ||||||||
| FaxNumber: | 4234954934 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 GLENWOOD DRIVE | ||||||||
| Address2: | SUITE W-462 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233624554 | ||||||||
| FaxNumber: | 4233624550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 08/15/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 43386 | GA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 043386 | GA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 30153 | TN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 3824599 | 01 | TN | MEDICARE | OTHER | 000796595C | 05 | GA | MEDICAID |