Provider Demographics
NPI:1881735835
Name:DONALD E HUNNESHAGEN M D INC & MICHAEL KETELAAR M D PTR HUNNESHAGEN DO
Entity type:Organization
Organization Name:DONALD E HUNNESHAGEN M D INC & MICHAEL KETELAAR M D PTR HUNNESHAGEN DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:KETELAAR
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:209-368-7121
Mailing Address - Street 1:1231 W VINE ST
Mailing Address - Street 2:SUITE 19
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5109
Mailing Address - Country:US
Mailing Address - Phone:209-368-7121
Mailing Address - Fax:209-368-5750
Practice Address - Street 1:1231 W VINE ST
Practice Address - Street 2:SUITE 19
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5109
Practice Address - Country:US
Practice Address - Phone:209-368-7121
Practice Address - Fax:209-368-5750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1487705935OtherNPI
CAA37149Medicare UPIN