Provider Demographics
NPI:1457318966
Name:HETLAND, RUTH ELLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:RUTH
Middle Name:ELLEN
Last Name:HETLAND
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 1:2235 CLINTON AVE S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-2623
Mailing Address - Country:US
Mailing Address - Phone:585-454-6720
Mailing Address - Fax:585-454-7328
Practice Address - Street 1:2235 CLINTON AVE S
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2623
Practice Address - Country:US
Practice Address - Phone:585-454-6720
Practice Address - Fax:585-454-7328
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149798208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00718956Medicaid
NY17601BMedicare ID - Type Unspecified
NY00718956Medicaid