Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | OPT15222 | CA |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | OPT15222 | CA |
NPI | 1154701001 |
---|---|
Provider Name | Colton Mark Heinrich |
First Address | Fullerton, CA 92831-1615 |
Second Address | Fullerton, CA 92831-1615 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/06/2015 |
Last Update Date | 05/06/2015 |