Provider Demographics
NPI:1679012868
Name:KETTELHUT, ERIKA (DO)
Entity type:Individual
Prefix:
First Name:ERIKA
Middle Name:
Last Name:KETTELHUT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6730 N WEST AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-4301
Mailing Address - Country:US
Mailing Address - Phone:559-439-3000
Mailing Address - Fax:559-439-3004
Practice Address - Street 1:6730 N WEST AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-4301
Practice Address - Country:US
Practice Address - Phone:559-439-3000
Practice Address - Fax:559-439-3004
Is Sole Proprietor?:No
Enumeration Date:2017-02-21
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151011140207N00000X, 207N00000X
KY05037207N00000X
390200000X
OH34.014997207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program