Provider Demographics
NPI:1669544110
Name:HENAO, GWENDOLYN (MD)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:HENAO
Suffix:
Gender:F
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:PO BOX 9894
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA FE
Mailing Address - State:CA
Mailing Address - Zip Code:92067-4894
Mailing Address - Country:US
Mailing Address - Phone:858-832-8404
Mailing Address - Fax:888-374-2984
Practice Address - Street 1:12264 EL CAMINO REAL
Practice Address - Street 2:SUITE 204
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3058
Practice Address - Country:US
Practice Address - Phone:858-832-8404
Practice Address - Fax:888-374-2984
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92651207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA92651AMedicare ID - Type Unspecified
CAI48480Medicare UPIN