Provider Demographics
NPI:1134100415
Name:HETTLE, MATTHEW WILLMAN (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WILLMAN
Last Name:HETTLE
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 1:4466 W BRISTOL RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-3170
Mailing Address - Country:US
Mailing Address - Phone:810-733-1200
Mailing Address - Fax:810-733-0688
Practice Address - Street 1:4466 W BRISTOL RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3170
Practice Address - Country:US
Practice Address - Phone:810-733-1200
Practice Address - Fax:810-733-0688
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065543208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0B51156OtherGROUP BCBS
0N45090OtherGROUP MEDICARE
MI4303713Medicaid
1215930490OtherTYPE 2 NPI
CB0923OtherGROUP RAILROAD
H17026Medicare UPIN
0N45090005Medicare ID - Type Unspecified