Provider Demographics
NPI:1881634566
Name:WETZEL, ELIZABETH A
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:WETZEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 M 62
Mailing Address - Street 2:
Mailing Address - City:CASSOPOLIS
Mailing Address - State:MI
Mailing Address - Zip Code:49031-1034
Mailing Address - Country:US
Mailing Address - Phone:269-445-3874
Mailing Address - Fax:269-445-1930
Practice Address - Street 1:261 M 62
Practice Address - Street 2:
Practice Address - City:CASSOPOLIS
Practice Address - State:MI
Practice Address - Zip Code:49031-1034
Practice Address - Country:US
Practice Address - Phone:269-445-3874
Practice Address - Fax:269-445-1930
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02002169A207Q00000X
MI5101011724207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200260320BMedicaid
IN200260320BMedicaid