Provider Demographics
NPI:1164983938
Name:HETZEL, MICHAEL JARED
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JARED
Last Name:HETZEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39000 BOB HOPE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3296
Mailing Address - Country:US
Mailing Address - Phone:760-340-3911
Mailing Address - Fax:760-835-0397
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3296
Practice Address - Country:US
Practice Address - Phone:760-340-3911
Practice Address - Fax:760-835-0397
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A19407207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program