Provider Demographics
NPI:1679547038
Name:HEISE, BRIAN A (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:A
Last Name:HEISE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:330 LEE DR.
Mailing Address - Street 2:SUITE B
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-1601
Mailing Address - Country:US
Mailing Address - Phone:225-926-4780
Mailing Address - Fax:225-926-4783
Practice Address - Street 1:330 LEE DR.
Practice Address - Street 2:SUITE B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-1601
Practice Address - Country:US
Practice Address - Phone:225-926-4780
Practice Address - Fax:225-926-4783
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.12387R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA01-02804OtherUNITED HEALTH PLAN
LA1429171Medicaid
LA5780698OtherAETNA HEALTH PLAN
LA1429171Medicaid
LA5780698OtherAETNA HEALTH PLAN