Provider Demographics
NPI:1174558985
Name:HETLAND, ROBERT LYTTON (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:LYTTON
Last Name:HETLAND
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1395 SAN CARLOS AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-2388
Mailing Address - Country:US
Mailing Address - Phone:650-802-9921
Mailing Address - Fax:650-802-9923
Practice Address - Street 1:1395 SAN CARLOS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-2388
Practice Address - Country:US
Practice Address - Phone:650-802-9921
Practice Address - Fax:650-802-9923
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2016-06-22
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Provider Licenses
StateLicense IDTaxonomies
CAA22540207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11002645OtherCAQH PROVIDER ID
CA4056691OtherAETNA ID
CA00A225400Medicaid
CAP00205050OtherRAILROAD MEDICARE