Provider Demographics
NPI:1083102883
Name:HETZMAN, MARGAUX MAE (MD)
Entity Type:Individual
Prefix:
First Name:MARGAUX
Middle Name:MAE
Last Name:HETZMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 KRESGE WAY STE 308
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4637
Mailing Address - Country:US
Mailing Address - Phone:502-895-8911
Mailing Address - Fax:502-895-8977
Practice Address - Street 1:3950 KRESGE WAY STE 308
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4637
Practice Address - Country:US
Practice Address - Phone:502-852-5666
Practice Address - Fax:502-852-8980
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP049207R00000X
390200000X
KY55566207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100606960Medicaid