Provider Demographics
NPI:1336257971
Name:HENNEBERRY, MICHAEL O (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:O
Last Name:HENNEBERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 E 64TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-6768
Mailing Address - Country:US
Mailing Address - Phone:509-448-2558
Mailing Address - Fax:
Practice Address - Street 1:820 S MCCLELLAN ST
Practice Address - Street 2:SUITE 118
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2457
Practice Address - Country:US
Practice Address - Phone:509-747-3147
Practice Address - Fax:509-747-0020
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 00013902208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA340011620OtherRRB
WA22139OtherL&I
WA8250003Medicaid
WA340011620OtherRRB
WA000359102Medicare PIN