Provider Demographics
NPI:1033135868
Name:HENRETTA, JOHN P (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:HENRETTA
Suffix:
Gender:M
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:PO BOX 1987
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1987
Mailing Address - Country:US
Mailing Address - Phone:877-685-2164
Mailing Address - Fax:317-705-5060
Practice Address - Street 1:222 ASHELAND AVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4016
Practice Address - Country:US
Practice Address - Phone:828-213-9090
Practice Address - Fax:828-213-9091
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC99011982086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8912394Medicaid
NC12394OtherBCBSNC
NC2277871BMedicare PIN
NC12394OtherBCBSNC
NC2277871AMedicare PIN