Provider Demographics
NPI:1518952613
Name:HENCEROTH, WILLIAM D II (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:D
Last Name:HENCEROTH
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:785 OHIO AVE
Mailing Address - Street 2:SUITE 1H
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-6217
Mailing Address - Country:US
Mailing Address - Phone:662-621-2438
Mailing Address - Fax:662-621-2469
Practice Address - Street 1:785 OHIO AVE
Practice Address - Street 2:SUITE 1H
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6217
Practice Address - Country:US
Practice Address - Phone:662-621-2438
Practice Address - Fax:662-621-2469
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101025812207X00000X
MS21213207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010012449Medicaid
VA00V603O33Medicare PIN
VAC36540Medicare UPIN
P00087106Medicare PIN