Provider Demographics
NPI:1255338786
Name:HENWOOD, JON R (DO)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:R
Last Name:HENWOOD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 807
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:PA
Mailing Address - Zip Code:16146
Mailing Address - Country:US
Mailing Address - Phone:724-981-7146
Mailing Address - Fax:724-981-8940
Practice Address - Street 1:705 BROOKSHIRE DR
Practice Address - Street 2:STE 3
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-4513
Practice Address - Country:US
Practice Address - Phone:724-981-7146
Practice Address - Fax:724-981-8940
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007593L208600000X
PAOS007953L2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015953740005Medicaid
PA890777Medicare ID - Type Unspecified
PA0015953740005Medicaid