MEDICARE: THERESA HETZLER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	042.0013055	VT
2	208000000X	Pediatrics Physician	181118	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619978293
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA HETZLER MD

Provider Business Mailing Address
First Line	:	505 E 70TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10021-4872
Country	:	US
Telephone Number	:	212-746-3303
Fax Number	:	212-746-8503

Provider Business Practice Location Address
First Line	:	505 E 70TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10021-4872
Country	:	US
Telephone Number	:	212-746-3303
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	10/29/2025

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