Provider Demographics
NPI:1720012107
Name:HENTZ, ROBERT (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:HENTZ
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 1:3900 LAKEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-5698
Mailing Address - Country:US
Mailing Address - Phone:707-765-3597
Mailing Address - Fax:707-765-3471
Practice Address - Street 1:3900 LAKEVILLE HWY
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-5698
Practice Address - Country:US
Practice Address - Phone:707-765-3597
Practice Address - Fax:707-765-3471
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC147601207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV5700AMedicare PIN
VA333449YWAUMedicare PIN