Provider Demographics
NPI:1073597852
Name:HENSLEY, EDWARD KIP (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:KIP
Last Name:HENSLEY
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 1:411 W 20TH ST
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-3713
Mailing Address - Country:US
Mailing Address - Phone:209-722-8122
Mailing Address - Fax:209-722-9849
Practice Address - Street 1:411 W 20TH ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-3713
Practice Address - Country:US
Practice Address - Phone:209-722-8122
Practice Address - Fax:209-722-9849
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG432012086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G432010Medicaid
F05935Medicare UPIN
CA00G432010Medicaid