Provider Demographics
NPI:1013029487
Name:HETTENA, AVI J (MD)
Entity Type:Individual
Prefix:DR
First Name:AVI
Middle Name:J
Last Name:HETTENA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:N/A
Mailing Address - Street 1:PO BOX 7281
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA FE
Mailing Address - State:CA
Mailing Address - Zip Code:92067-7281
Mailing Address - Country:US
Mailing Address - Phone:518-637-8637
Mailing Address - Fax:415-358-4754
Practice Address - Street 1:6037 LA GRANADA, SUITE C
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA FE
Practice Address - State:CA
Practice Address - Zip Code:92067
Practice Address - Country:US
Practice Address - Phone:858-756-2116
Practice Address - Fax:858-400-5113
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45263207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G452630Medicaid
CA110017611OtherMEDICARE RAILROAD
CA110017611OtherMEDICARE RAILROAD
CA00G452630Medicare ID - Type Unspecified