1255394029 NPI number — DR. STEVEN MATTHEW HETRICK MD, MPH

Table of content: DR. STEVEN MATTHEW HETRICK MD, MPH (NPI 1255394029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255394029 NPI number — DR. STEVEN MATTHEW HETRICK MD, MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HETRICK
Provider First Name:
STEVEN
Provider Middle Name:
MATTHEW
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, MPH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255394029
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 WILFORD HALL LOOP BLDG 4554
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JBSA LACKLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78236-5638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-292-1184
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
559 AMDS/SGPF
Provider Second Line Business Practice Location Address:
1940 CARSWELL AVENUE BUILDING 7002
Provider Business Practice Location Address City Name:
JBSA--LACKLAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-292-9655
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2083P0500X , with the licence number:  182062-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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