Provider Demographics
NPI:1457332777
Name:TETZ, EMMETT LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:EMMETT
Middle Name:LEE
Last Name:TETZ
Suffix:
Gender:M
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 340
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94576-0340
Mailing Address - Country:US
Mailing Address - Phone:707-963-5239
Mailing Address - Fax:707-963-0752
Practice Address - Street 1:6 WOODLAND RD
Practice Address - Street 2:201
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-9501
Practice Address - Country:US
Practice Address - Phone:707-963-5239
Practice Address - Fax:707-963-0752
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG11748208600000X, 2086S0129X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G117480Medicare ID - Type Unspecified
CAA38437Medicare UPIN