Provider Demographics
NPI:1588733497
Name:HENEGAR, EDWARD (DO)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:HENEGAR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 N KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-2029
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:404 HIGHWAY 160
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:MO
Practice Address - Zip Code:65655
Practice Address - Country:US
Practice Address - Phone:417-679-4613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO35006207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR120405729Medicaid
AR120405729Medicaid