Provider Demographics
NPI:1891781621
Name:HENSTORF, JAN ERIC (MD)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:ERIC
Last Name:HENSTORF
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 1:39141 CIVIC CENTER DR
Mailing Address - Street 2:SUITE 315
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-5818
Mailing Address - Country:US
Mailing Address - Phone:510-248-1000
Mailing Address - Fax:510-608-6055
Practice Address - Street 1:38690 STIVERS ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-5279
Practice Address - Country:US
Practice Address - Phone:510-248-1040
Practice Address - Fax:510-797-7426
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA448840207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A448840Medicaid
A29795Medicare UPIN
CA00A448840Medicaid