Provider Demographics
NPI:1306838610
Name:HETSKO, RICHARD JAMES (AUD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JAMES
Last Name:HETSKO
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:OBERLIN
Mailing Address - State:OH
Mailing Address - Zip Code:44074-1473
Mailing Address - Country:US
Mailing Address - Phone:440-775-1083
Mailing Address - Fax:440-774-5920
Practice Address - Street 1:224 W LORAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:OBERLIN
Practice Address - State:OH
Practice Address - Zip Code:44074-1096
Practice Address - Country:US
Practice Address - Phone:440-774-5819
Practice Address - Fax:440-774-5920
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA0006237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2245903Medicaid
OHHE9314661Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
OH2245903Medicaid
OHHE0419454Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER