Provider Demographics
NPI:1144200486
Name:HENJUM, STANLEY C II (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:C
Last Name:HENJUM
Suffix:II
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 45680
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94145-0680
Mailing Address - Country:US
Mailing Address - Phone:530-626-9488
Mailing Address - Fax:
Practice Address - Street 1:1004 FOWLER WAY
Practice Address - Street 2:#4
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-5746
Practice Address - Country:US
Practice Address - Phone:530-626-9488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG62392207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G623920Medicaid
CA90095380OtherRAILROAD MEDICARE
CA00G623920Medicaid
CA00G623921Medicare PIN