Provider Demographics
NPI:1962793422
Name:HENIN, MARK DAVID (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:HENIN
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:PO BOX 603949
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3949
Mailing Address - Country:US
Mailing Address - Phone:919-350-0351
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:23 SUNNYBROOK RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1855
Practice Address - Country:US
Practice Address - Phone:919-350-7584
Practice Address - Fax:919-231-0314
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-02
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC173590208000000X
NC2014-00498208000000X, 2080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1962793422Medicaid
SC368364Medicaid
NC1962793422Medicaid
NCNCK148AMedicare PIN
NCNCK1480386Medicare PIN