Provider Demographics
NPI:1770531295
Name:ETZEL, KATHLEEN D (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:D
Last Name:ETZEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 ACEE DRIVE
Mailing Address - Street 2:
Mailing Address - City:NATRONA HEIGHTS
Mailing Address - State:PA
Mailing Address - Zip Code:15065
Mailing Address - Country:US
Mailing Address - Phone:800-223-5544
Mailing Address - Fax:724-294-3206
Practice Address - Street 1:406 W OAK STREET
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16354
Practice Address - Country:US
Practice Address - Phone:814-827-1851
Practice Address - Fax:724-226-4575
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD049657L2085R0202X, 2085B0100X, 2085N0904X, 2085P0229X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00143495OtherRR MEDICARE
0018069510004OtherMA
PA0018069510004Medicaid
141309OtherBLUE SHIELD
141309OtherBLUE SHIELD
E97611Medicare UPIN
PA040095Medicare ID - Type Unspecified