Basic Information
| Provider Information | |||||||||
| NPI: | 1083102883 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HETZMAN | ||||||||
| FirstName: | MARGAUX | ||||||||
| MiddleName: | MAE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3950 KRESGE WAY STE 308 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028958911 | ||||||||
| FaxNumber: | 5028958977 | ||||||||
| Practice Location | |||||||||
| Address1: | 3950 KRESGE WAY STE 308 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028525666 | ||||||||
| FaxNumber: | 5028528980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2018 | ||||||||
| LastUpdateDate: | 06/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | TP049 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 55566 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100606960 | 05 | KY | MEDICAID |