Provider Demographics
NPI:1699765412
Name:HENNESSY, ROBERT
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:HENNESSY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3593 ARBORETUM CIR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-3973
Mailing Address - Country:US
Mailing Address - Phone:714-943-5015
Mailing Address - Fax:
Practice Address - Street 1:3593 ARBORETUM CIR
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-3973
Practice Address - Country:US
Practice Address - Phone:714-943-5015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1145382083X0100X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01820891Medicaid
NYG45952Medicare UPIN
NY01820891Medicaid