1962535419 NPI number — DR. LARRY KENNETH HETRICK JR. M.D.

Table of content: DR. LARRY KENNETH HETRICK JR. M.D. (NPI 1962535419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962535419 NPI number — DR. LARRY KENNETH HETRICK JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HETRICK
Provider First Name:
LARRY
Provider Middle Name:
KENNETH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
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:
1962535419
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 14880
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94114-0880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-567-0321
Provider Business Mailing Address Fax Number:
415-895-5548

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
606 WILSON AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NOVATO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94947-3817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-567-0321
Provider Business Practice Location Address Fax Number:
415-647-0321
Provider Enumeration Date:
03/13/2007

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: 2084P0800X , with the licence number:  G078733 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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