Provider Demographics
NPI:1295700730
Name:W D HENCEROTH DO INC
Entity type:Organization
Organization Name:W D HENCEROTH DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HENCEROTH GATTO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:614-875-6349
Mailing Address - Street 1:3774 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-2235
Mailing Address - Country:US
Mailing Address - Phone:614-875-6349
Mailing Address - Fax:614-875-3633
Practice Address - Street 1:3774 BROADWAY
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-2235
Practice Address - Country:US
Practice Address - Phone:614-875-6349
Practice Address - Fax:614-875-3633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH402712207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH=========OtherTAX ID