Provider Demographics
NPI:1255332987
Name:HENDERSHOT, JACK GG JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:GG
Last Name:HENDERSHOT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:15840 MEDICAL DRIVE SOUTH
Mailing Address - Street 2:SUITE A
Mailing Address - City:FINDLAY
Mailing Address - State:OH
Mailing Address - Zip Code:45840
Mailing Address - Country:US
Mailing Address - Phone:419-422-6190
Mailing Address - Fax:419-423-3235
Practice Address - Street 1:15840 MEDICAL DRIVE SOUTH
Practice Address - Street 2:SUITE A
Practice Address - City:FINDLAY
Practice Address - State:OH
Practice Address - Zip Code:45840
Practice Address - Country:US
Practice Address - Phone:419-422-6190
Practice Address - Fax:419-423-3235
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH37324207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0277276Medicaid
OH000000129596OtherANTHEM BCBS
OH4281257OtherAETNA
OH037324OtherSTATE LICENSE
OH037324OtherSTATE LICENSE
OH0277276Medicaid
OH0403511Medicare ID - Type Unspecified