Provider Demographics
NPI:1689129702
Name:HEFFERNAN, JEREMY REID (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:REID
Last Name:HEFFERNAN
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 1:22250 PROVIDENCE DR STE 301
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-6211
Mailing Address - Country:US
Mailing Address - Phone:248-849-3281
Mailing Address - Fax:248-849-8027
Practice Address - Street 1:22250 PROVIDENCE DR STE 301
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-6211
Practice Address - Country:US
Practice Address - Phone:248-849-3281
Practice Address - Fax:248-849-8027
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAP2742713-356207R00000X
MI4301500220207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine