Provider Demographics
NPI:1235165861
Name:HENEVELD, EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:HENEVELD
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 2488
Mailing Address - Street 2:
Mailing Address - City:OLYMPIC VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:96146-2488
Mailing Address - Country:US
Mailing Address - Phone:530-583-1817
Mailing Address - Fax:530-583-1557
Practice Address - Street 1:10121 PINE AVE
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-4835
Practice Address - Country:US
Practice Address - Phone:530-582-3209
Practice Address - Fax:530-582-3201
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29319207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G293190Medicaid
CA00G293190Medicaid
CA00G243190Medicare ID - Type Unspecified