Provider Demographics
NPI:1699970806
Name:HETZEL, ERIC LEE (DO)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:LEE
Last Name:HETZEL
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 1:6945 TUTT BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80923-3566
Mailing Address - Country:US
Mailing Address - Phone:719-380-7325
Mailing Address - Fax:719-354-2212
Practice Address - Street 1:6945 TUTT BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80923-3566
Practice Address - Country:US
Practice Address - Phone:719-380-7325
Practice Address - Fax:719-354-2212
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0054267207Q00000X
KS05-33464207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1699970806Medicaid