Provider Demographics
NPI:1558346866
Name:HETZ, ROBERT NOLAN (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:NOLAN
Last Name:HETZ
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 1:304 N RAPIDS RD
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-3408
Mailing Address - Country:US
Mailing Address - Phone:920-683-0321
Mailing Address - Fax:920-683-9078
Practice Address - Street 1:304 N RAPIDS RD
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-3408
Practice Address - Country:US
Practice Address - Phone:920-683-0321
Practice Address - Fax:920-683-9078
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29141020207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31406900Medicaid
WI31406900Medicaid
WI000138255Medicare PIN