Provider Demographics
NPI:1134198476
Name:DAVE, HETAL R (MD)
Entity type:Individual
Prefix:
First Name:HETAL
Middle Name:R
Last Name:DAVE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-2512
Mailing Address - Country:US
Mailing Address - Phone:603-663-7030
Mailing Address - Fax:603-663-7039
Practice Address - Street 1:138 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-2512
Practice Address - Country:US
Practice Address - Phone:603-663-7030
Practice Address - Fax:603-663-7039
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH12651207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3080134Medicaid
NHP00228882OtherRR MEDICARE
NH3080134Medicaid
NHAA29297OtherHPHC
NH30977YOtherANTHEM REFERRING RAN
NH7625681OtherAETNA PIN
H97179Medicare UPIN
NHRE8185Medicare PIN
NH01Y008246NH01OtherANTHEM ACES #
NH30204924Medicaid