Basic Information
| Provider Information | |||||||||
| NPI: | 1174620496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEAPHY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | RILEY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 640 W MOANA LN | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895094903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753240699 | ||||||||
| FaxNumber: | 7753236814 | ||||||||
| Practice Location | |||||||||
| Address1: | 4814 SPARKS BLVD | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753240699 | ||||||||
| FaxNumber: | 7753236814 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0900X | ME97172 | FL | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ND0900X | 35.088653 | OH | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ZD0900X | T4386 | TX | N | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207N00000X | ME97172 | FL | N | Allopathic & Osteopathic Physicians | Dermatology | 207ND0900X | 17674 | NV | Y | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology |
ID Information
| ID | Type | State | Issuer | Description | AB222U | 01 | FL | MEDICARE PTAN | OTHER |