Provider Demographics
NPI:1013143742
Name:ETZEL, ANDREW KENNETH (DO)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:KENNETH
Last Name:ETZEL
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 1:109 MOUNT WOOD RD
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-2632
Mailing Address - Country:US
Mailing Address - Phone:304-234-2455
Mailing Address - Fax:304-233-6073
Practice Address - Street 1:2115 CHAPLINE ST
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3859
Practice Address - Country:US
Practice Address - Phone:304-234-8885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2251207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810015261Medicaid
WVP00960914OtherRAILROAD MEDICARE PIN
OH2967768Medicaid
WVP00960914OtherRAILROAD MEDICARE PIN