Provider Demographics
NPI:1942274691
Name:HETRICK, RICHARD B (OD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:B
Last Name:HETRICK
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 1:1801 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-4938
Mailing Address - Country:US
Mailing Address - Phone:814-455-8004
Mailing Address - Fax:814-456-6054
Practice Address - Street 1:1801 W 8TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-4938
Practice Address - Country:US
Practice Address - Phone:814-455-8004
Practice Address - Fax:814-456-6054
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001090152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA060638Medicare ID - Type UnspecifiedMEDICARE GROUP #
PA436660QWBMedicare ID - Type UnspecifiedHETRICK IND MEDICARE 3
PAT30428Medicare UPIN