Provider Demographics
NPI:1205940889
Name:HENSHAW, WILLIAM C (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:C
Last Name:HENSHAW
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 1:801 S FAIRMONT AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5106
Mailing Address - Country:US
Mailing Address - Phone:209-334-2020
Mailing Address - Fax:209-333-2015
Practice Address - Street 1:801 S FAIRMONT AVE STE 5
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5106
Practice Address - Country:US
Practice Address - Phone:209-334-2020
Practice Address - Fax:209-333-2015
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5036 TPA152W00000X, 152WC0802X, 152WV0400X
CA50360 TPA152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0050360Medicaid
CA5036 TPAOtherOPTOMETRY LICENSE
CAMH1177915OtherDEA #
CAT09860Medicare UPIN
CASD0050360Medicare PIN