Healthcare Provider Details

I. General information

NPI: 1437619293
Provider Name (Legal Business Name): PETER THEODORE HETZLER III MD, MHS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WOODS RD
VALHALLA NY
10595-1530
US

IV. Provider business mailing address

100 WOODS RD
VALHALLA NY
10595-1530
US

V. Phone/Fax

Practice location:
  • Phone: 914-909-6416
  • Fax:
Mailing address:
  • Phone: 914-909-6416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number346613-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: