Provider Demographics
NPI:1851335863
Name:HENESCH, STEPHEN MARK (D O)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MARK
Last Name:HENESCH
Suffix:
Gender:M
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5918
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-5918
Mailing Address - Country:US
Mailing Address - Phone:800-827-8415
Mailing Address - Fax:315-295-2117
Practice Address - Street 1:1000 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4927
Practice Address - Country:US
Practice Address - Phone:631-376-4027
Practice Address - Fax:631-376-4046
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2389912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02801009Medicaid
NY02801009Medicaid