Provider Demographics
NPI:1396704649
Name:HENNER, MICHAEL S (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:HENNER
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 1:515 W STATE ROAD 434
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4981
Mailing Address - Country:US
Mailing Address - Phone:407-332-8080
Mailing Address - Fax:407-260-0602
Practice Address - Street 1:2850 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6610
Practice Address - Country:US
Practice Address - Phone:352-383-0733
Practice Address - Fax:352-383-7112
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64349174400000X, 207ZD0900X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No174400000XOther Service ProvidersSpecialist
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE54297Medicare UPIN
FL99529Medicare PIN