MEDICARE: DR. JOHN L HENAHAN OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT001788	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	721256052	OTHER	LA	TAX ID
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730170788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN L HENAHAN OD

Provider Business Mailing Address
First Line	:	361 HIGHWAY 74 N
Second Line	:
City	:	PEACHTREE CITY
State	:	GA
Zip	:	30269-1102
Country	:	US
Telephone Number	:	770-487-0667
Fax Number	:	770-487-0947

Provider Business Practice Location Address
First Line	:	361 HIGHWAY 74 N
Second Line	:
City	:	PEACHTREE CITY
State	:	GA
Zip	:	30269-1102
Country	:	US
Telephone Number	:	770-487-0667
Fax Number	:	770-487-0947

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	08/01/2025

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