Provider Demographics
NPI:1942295464
Name:HETZNER, MICHAEL H (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:H
Last Name:HETZNER
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 1:632 FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:KIEL
Mailing Address - State:WI
Mailing Address - Zip Code:53042-1321
Mailing Address - Country:US
Mailing Address - Phone:920-894-3322
Mailing Address - Fax:
Practice Address - Street 1:632 FREMONT ST
Practice Address - Street 2:
Practice Address - City:KIEL
Practice Address - State:WI
Practice Address - Zip Code:53042-1321
Practice Address - Country:US
Practice Address - Phone:920-894-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27988207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30040900Medicaid
WI027771018Medicare PIN
B84920Medicare UPIN