Provider Demographics
NPI:1902808645
Name:HENAO, JUSTINE ELODIA (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTINE
Middle Name:ELODIA
Last Name:HENAO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1200 NORTHSIDE FORSYTH DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-7659
Mailing Address - Country:US
Mailing Address - Phone:770-844-3200
Mailing Address - Fax:404-851-6325
Practice Address - Street 1:1200 NORTHSIDE FORSYTH DR
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7659
Practice Address - Country:US
Practice Address - Phone:770-844-3200
Practice Address - Fax:404-851-6325
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052580207R00000X, 208M00000X
TXU5861207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA608048816AMedicaid
GA52703489OtherBLUE CROSS BLUE SHIELD
GA511I110007Medicare PIN
GA52703489OtherBLUE CROSS BLUE SHIELD