Provider Demographics
NPI:1053364562
Name:HEIMULLER, BRENT (MD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:HEIMULLER
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 1:2435 NE CUMULUS AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-8862
Mailing Address - Country:US
Mailing Address - Phone:503-472-6161
Mailing Address - Fax:503-434-6290
Practice Address - Street 1:2435 NE CUMULUS AVE STE A
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-8862
Practice Address - Country:US
Practice Address - Phone:503-472-6161
Practice Address - Fax:503-434-6290
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18814208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR082284Medicaid
G32439Medicare UPIN
OR082284Medicaid