Provider Demographics
NPI:1821143744
Name:HENSLEY, MICHAEL JERRY (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JERRY
Last Name:HENSLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 TYLER ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3458
Mailing Address - Country:US
Mailing Address - Phone:951-687-7100
Mailing Address - Fax:951-687-1663
Practice Address - Street 1:4000 TYLER ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3458
Practice Address - Country:US
Practice Address - Phone:951-687-7100
Practice Address - Fax:951-687-1663
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9762152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA50482Medicare UPIN