Provider Demographics
NPI:1962535419
Name:HETRICK, LARRY KENNETH JR (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:KENNETH
Last Name:HETRICK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:P.O. BOX 14880
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-0880
Mailing Address - Country:US
Mailing Address - Phone:415-567-0321
Mailing Address - Fax:415-895-5548
Practice Address - Street 1:606 WILSON AVENUE
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-3817
Practice Address - Country:US
Practice Address - Phone:415-567-0321
Practice Address - Fax:415-647-0321
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG0787332084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry