Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 5036 TPA | CA |
N | 152WC0802X | Optomitrist - Corneal and Contact Lenses | 5036 TPA | CA |
N | 152WS0006X | Sports Vision | 50360 TPA | CA |
N | 152WV0400X | Optomitrist - Vision Therapist | 5036 TPA | CA |
NPI | 1205940889 |
---|---|
Provider Name | Dr. William C Henshaw |
First Address | Lodi, CA 95240-5106 |
Second Address | Lodi, CA 95240-5106 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2006 |
Last Update Date | 16/07/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
5036 TPA | OPTOMETRY LICENSE (01) | CA |
MH1177915 | DEA # (01) | CA |
SD0050360 | (05) | CA |
T09860 | (02) | CA |