1730170788 NPI number — DR. JOHN L HENAHAN OD

Table of content: DR. JOHN L HENAHAN OD (NPI 1730170788)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730170788 NPI number — DR. JOHN L HENAHAN OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENAHAN
Provider First Name:
JOHN
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730170788
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
361 HIGHWAY 74 N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEACHTREE CITY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30269-1102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-487-0667
Provider Business Mailing Address Fax Number:
770-487-0947

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
361 HIGHWAY 74 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEACHTREE CITY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30269-1102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-487-0667
Provider Business Practice Location Address Fax Number:
770-487-0947
Provider Enumeration Date:
10/31/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT001788 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 721256052 . This is a "TAX ID" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 00844181A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".