Provider Demographics
NPI:1578946265
Name:HETKE, DUSTIN (OD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:HETKE
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 1:2303 SCHNEIDER AVE SE STE 100
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-7007
Mailing Address - Country:US
Mailing Address - Phone:715-235-3838
Mailing Address - Fax:715-235-3846
Practice Address - Street 1:2303 SCHNEIDER AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-7007
Practice Address - Country:US
Practice Address - Phone:715-235-3838
Practice Address - Fax:715-235-3846
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3386-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist