Provider Demographics
NPI:1194893313
Name:JONATHAN K HETZEL, MD
Entity type:Organization
Organization Name:JONATHAN K HETZEL, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HETZEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-363-8260
Mailing Address - Street 1:80 W WELSH POOL RD
Mailing Address - Street 2:SUITE 200 SOUTH
Mailing Address - City:EXTON
Mailing Address - State:PA
Mailing Address - Zip Code:19341-1233
Mailing Address - Country:US
Mailing Address - Phone:610-363-8260
Mailing Address - Fax:610-363-8002
Practice Address - Street 1:80 W WELSH POOL RD
Practice Address - Street 2:SUITE 200 SOUTH
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-1233
Practice Address - Country:US
Practice Address - Phone:610-363-8260
Practice Address - Fax:610-363-8002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-018132-E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB34691Medicare UPIN
PA064046Medicare ID - Type UnspecifiedMEDICARE NUMBER