Provider Demographics
NPI:1699798041
Name:HENSGEN, KELLY J (DO)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:J
Last Name:HENSGEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MEMORIAL CIR STE C
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5054
Mailing Address - Country:US
Mailing Address - Phone:386-615-3500
Mailing Address - Fax:386-615-3505
Practice Address - Street 1:500 MEMORIAL CIR STE C
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5054
Practice Address - Country:US
Practice Address - Phone:386-615-3500
Practice Address - Fax:386-615-3505
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5951207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80666Medicare ID - Type Unspecified
FLF35028Medicare UPIN