Provider Demographics
NPI:1932101730
Name:HETRICK, STUART JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:STUART
Middle Name:JOHN
Last Name:HETRICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 39179
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85069-9179
Mailing Address - Country:US
Mailing Address - Phone:602-395-0718
Mailing Address - Fax:602-277-8146
Practice Address - Street 1:4530 E MUIRWOOD DR
Practice Address - Street 2:#111
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7639
Practice Address - Country:US
Practice Address - Phone:480-961-2365
Practice Address - Fax:480-961-2382
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31032084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZE47394Medicare UPIN
AZZ66210Medicare PIN