Basic Information
| Provider Information | |||||||||
| NPI: | 1558374454 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HIEMSTRA | ||||||||
| FirstName: | RON | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6101 BLUE LAGOON DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331262051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055002027 | ||||||||
| FaxNumber: | 3055002155 | ||||||||
| Practice Location | |||||||||
| Address1: | 3854 BRITTON PLZ | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336111406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138372814 | ||||||||
| FaxNumber: | 8668532860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME115467 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 14T4Y | 01 | FLORIDA BLUE | OTHER | 009595100 | 05 | FL | MEDICAID | 114638 | 01 | BLUE CROSS MO | OTHER |