Provider Demographics
NPI:1346221512
Name:HETZNER, PETER V (OD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:V
Last Name:HETZNER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 S HAM LN
Mailing Address - Street 2:STE B
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-3523
Mailing Address - Country:US
Mailing Address - Phone:209-368-5352
Mailing Address - Fax:209-368-5355
Practice Address - Street 1:421 S HAM LN
Practice Address - Street 2:STE B
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3523
Practice Address - Country:US
Practice Address - Phone:209-368-5352
Practice Address - Fax:209-368-5355
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5692TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ28009ZOtherBLUE SHIELD
CA0622870001OtherCIGNA MEDICARE
CASD0056920Medicaid
SD0056920Medicare ID - Type Unspecified
CASD0056920Medicaid
CA0622870001OtherCIGNA MEDICARE