Provider Demographics
NPI:1841226149
Name:HETNAL, MIECZYSLAW J (MD)
Entity Type:Individual
Prefix:
First Name:MIECZYSLAW
Middle Name:J
Last Name:HETNAL
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 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-521-6097
Mailing Address - Fax:
Practice Address - Street 1:3425 COFFEE RD
Practice Address - Street 2:SUITE 2A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1582
Practice Address - Country:US
Practice Address - Phone:209-524-9401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA466012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ18445ZMedicare PIN