Provider Demographics
NPI:1710905351
Name:HIETALA, STEPHEN R (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:HIETALA
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 1:665 3RD ST SW
Mailing Address - Street 2:
Mailing Address - City:PERHAM
Mailing Address - State:MN
Mailing Address - Zip Code:56573-1108
Mailing Address - Country:US
Mailing Address - Phone:218-347-1200
Mailing Address - Fax:218-346-4043
Practice Address - Street 1:665 3RD ST SW
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-1108
Practice Address - Country:US
Practice Address - Phone:218-347-1200
Practice Address - Fax:218-346-4043
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN28147207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D48649Medicare UPIN
MN080005898Medicare PIN