=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811980329
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT LOWELL HETZEL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2005
-----------------------------------------------------
Last Update Date | 01/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 224D CORNWALL ST NW SUITE 106
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20176-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-777-1612
-----------------------------------------------------
Fax | 703-777-2368
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 17334
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21297-1334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-443-6717
-----------------------------------------------------
Fax | 703-443-8643
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 0101232586
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------