Provider Demographics
NPI:1558374454
Name:HIEMSTRA, RON R (MD)
Entity Type:Individual
Prefix:DR
First Name:RON
Middle Name:R
Last Name:HIEMSTRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2051
Mailing Address - Country:US
Mailing Address - Phone:305-500-2027
Mailing Address - Fax:305-500-2155
Practice Address - Street 1:3854 BRITTON PLZ
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-1406
Practice Address - Country:US
Practice Address - Phone:813-837-2814
Practice Address - Fax:866-853-2860
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME115467207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
14T4YOtherFLORIDA BLUE
FL009595100Medicaid
114638OtherBLUE CROSS MO
A02374Medicare UPIN
114638OtherBLUE CROSS MO