Provider Demographics
NPI:1811980329
Name:HETZEL, ROBERT LOWELL (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:LOWELL
Last Name:HETZEL
Suffix:
Gender:M
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:PO BOX 17334
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-1334
Mailing Address - Country:US
Mailing Address - Phone:703-443-6717
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:224D CORNWALL ST NW
Practice Address - Street 2:SUITE 106
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-2700
Practice Address - Country:US
Practice Address - Phone:703-777-1612
Practice Address - Fax:703-777-2368
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2010-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101232586207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010105757Medicaid
VA010105706Medicaid
VA010105731Medicaid
P00270260OtherRR MEDICARE
VA010105757Medicaid
VA010105731Medicaid
VA886156L19Medicare PIN