Provider Demographics
NPI:1568811321
Name:HENNON, MARCUS R (DO)
Entity Type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:R
Last Name:HENNON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2418 W CRESTWOOD # MO65721
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-5997
Mailing Address - Country:US
Mailing Address - Phone:417-551-2203
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9210
Practice Address - Country:US
Practice Address - Phone:417-533-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-11
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125069113207Q00000X
MO2018022565207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine