Provider Demographics
NPI:1164417093
Name:HEDRICK, GUADALUPE NIETO (MD)
Entity Type:Individual
Prefix:
First Name:GUADALUPE
Middle Name:NIETO
Last Name:HEDRICK
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:PO BOX 898
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-0898
Mailing Address - Country:US
Mailing Address - Phone:707-236-2266
Mailing Address - Fax:
Practice Address - Street 1:445 MARCH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:HEALDSBURG
Practice Address - State:CA
Practice Address - Zip Code:95448-3383
Practice Address - Country:US
Practice Address - Phone:707-433-8223
Practice Address - Fax:707-431-1071
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01066640A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
637650ZMedicare Oscar/Certification