Provider Demographics
NPI:1952467557
Name:HITTENBERGER, DREW (CP,BOCO)
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:
Last Name:HITTENBERGER
Suffix:
Gender:M
Credentials:CP,BOCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 LYNCH CREEK WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-2380
Mailing Address - Country:US
Mailing Address - Phone:707-765-1122
Mailing Address - Fax:707-765-4571
Practice Address - Street 1:181 LYNCH CREEK WAY STE 101
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-2380
Practice Address - Country:US
Practice Address - Phone:707-765-1122
Practice Address - Fax:707-765-4571
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X
DECP 1093335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC000120Medicaid
CAGXC000120Medicaid