Healthcare Provider Details

I. General information

NPI: 1174620496
Provider Name (Legal Business Name): MICHAEL RILEY HEAPHY JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4814 SPARKS BLVD
SPARKS NV
89436
US

IV. Provider business mailing address

640 W MOANA LN
RENO NV
89509-4903
US

V. Phone/Fax

Practice location:
  • Phone: 775-324-0699
  • Fax: 775-323-6814
Mailing address:
  • Phone: 775-324-0699
  • Fax: 775-323-6814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberME97172
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number35.088653
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberT4386
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberME97172
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number17674
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: