Healthcare Provider Details

I. General information

NPI: 1346239944
Provider Name (Legal Business Name): BRET DOUGLAS HEEREMA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9800 W SKYE CANYON PARK DR STE 170
LAS VEGAS NV
89166-6631
US

IV. Provider business mailing address

9800 W SKYE CANYON PARK DR STE 170
LAS VEGAS NV
89166-6631
US

V. Phone/Fax

Practice location:
  • Phone: 702-425-5119
  • Fax:
Mailing address:
  • Phone: 702-425-5119
  • Fax: 702-213-6079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number24360
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number01059390A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number01059390A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number24360
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: