Provider Demographics
NPI:1730170788
Name:HENAHAN, JOHN L (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:HENAHAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:361 HIGHWAY 74 N
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-1102
Mailing Address - Country:US
Mailing Address - Phone:770-487-0667
Mailing Address - Fax:770-487-0947
Practice Address - Street 1:361 HIGHWAY 74 N
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1102
Practice Address - Country:US
Practice Address - Phone:770-487-0667
Practice Address - Fax:770-487-0947
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT001788152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA721256052OtherTAX ID
GA00844181AMedicaid
GA00844181AMedicaid
GA511I410075Medicare PIN