Provider Demographics
NPI:1780676676
Name:HENNESSY, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:HENNESSY
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 1:535 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-1513
Mailing Address - Country:US
Mailing Address - Phone:716-372-0141
Mailing Address - Fax:716-373-6632
Practice Address - Street 1:535 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1513
Practice Address - Country:US
Practice Address - Phone:716-372-0141
Practice Address - Fax:716-373-6632
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179364207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01139495Medicaid
NY01139495Medicaid
NYC84457Medicare UPIN