Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 001092 | NY |
Y | 213ES0000X | Sports Medicine | 001092 | NY |
NPI | 1164096962 |
---|---|
Provider Name | Douglas R Henneberg |
First Address | Rochester, NY 14623-5701 |
Second Address | Rochester, NY 14623-5701 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2021 |
Last Update Date | 17/05/2021 |