Provider Demographics
NPI:1124108998
Name:HENNON, MARK W (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:HENNON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ELM AND CARLTON ST
Mailing Address - Street 2:CANCER CENTER GROUND FLOOR
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14263
Mailing Address - Country:US
Mailing Address - Phone:716-845-2300
Mailing Address - Fax:
Practice Address - Street 1:ELM AND CARLTON ST
Practice Address - Street 2:CANCER CENTER GROUND FLOOR
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14263
Practice Address - Country:US
Practice Address - Phone:716-845-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY256860208G00000X
PAMD426092208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03226262Medicaid
NYJ400020739Medicare PIN