Provider Demographics
NPI:1215490008
Name:HENARY, MARK (MEDICAL DOCTOR)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HENARY
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 CESAR CHAVEZ AVENUE
Mailing Address - Street 2:SUITE #3900
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-2414
Mailing Address - Country:US
Mailing Address - Phone:323-307-0800
Mailing Address - Fax:323-307-0803
Practice Address - Street 1:2121 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2303
Practice Address - Country:US
Practice Address - Phone:310-453-1324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA182610208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program