Provider Demographics
NPI:1366463879
Name:HENRETIG, ROBERT D (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
Last Name:HENRETIG
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 1:150 TEJAS PL
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9123
Mailing Address - Country:US
Mailing Address - Phone:805-929-3211
Mailing Address - Fax:805-929-6359
Practice Address - Street 1:2180 JOHNSON AVE
Practice Address - Street 2:STE A
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4513
Practice Address - Country:US
Practice Address - Phone:805-269-1313
Practice Address - Fax:805-269-1387
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG168502085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8131633Medicaid
CAKFHC71031FMedicaid
CA051847Medicare Oscar/Certification
CAW1508EMedicare PIN
CAKFHC71031FMedicaid
CA551983Medicare Oscar/Certification
WA000194904Medicare ID - Type Unspecified
WA8131633Medicaid