Provider Demographics
NPI:1053497685
Name:HENEHAN, MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HENEHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 OCONNOR DR
Mailing Address - Street 2:STE 210
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1633
Mailing Address - Country:US
Mailing Address - Phone:408-995-5453
Mailing Address - Fax:408-275-9442
Practice Address - Street 1:455 OCONNOR DR
Practice Address - Street 2:STE 210
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1633
Practice Address - Country:US
Practice Address - Phone:408-995-5453
Practice Address - Fax:408-275-9442
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4724207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine