Provider Demographics
NPI:1174620496
Name:HEAPHY, MICHAEL RILEY JR (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:RILEY
Last Name:HEAPHY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:640 W MOANA LN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-4903
Mailing Address - Country:US
Mailing Address - Phone:775-324-0699
Mailing Address - Fax:775-323-6814
Practice Address - Street 1:4814 SPARKS BLVD
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89436
Practice Address - Country:US
Practice Address - Phone:775-324-0699
Practice Address - Fax:775-323-6814
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97172207ND0900X, 207N00000X
OH35.088653207ND0900X
TXT4386207ZD0900X
NV17674207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAB222UOtherMEDICARE PTAN
CAI46231Medicare UPIN