Healthcare Provider Details

I. General information

NPI: 1881735835
Provider Name (Legal Business Name): DONALD E HUNNESHAGEN M D INC & MICHAEL KETELAAR M D PTR HUNNESHAGEN DO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 06/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1231 W VINE ST SUITE 19
LODI CA
95240-5109
US

IV. Provider business mailing address

1231 W VINE ST SUITE 19
LODI CA
95240-5109
US

V. Phone/Fax

Practice location:
  • Phone: 209-368-7121
  • Fax: 209-368-5750
Mailing address:
  • Phone: 209-368-7121
  • Fax: 209-368-5750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL TIMOTHY KETELAAR
Title or Position: PARTNER
Credential: M D
Phone: 209-368-7121