Healthcare Provider Details

I. General information

NPI: 1699765412
Provider Name (Legal Business Name): ROBERT HENNESSY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3593 ARBORETUM CIR
CORONA CA
92881-3973
US

IV. Provider business mailing address

3593 ARBORETUM CIR
CORONA CA
92881-3973
US

V. Phone/Fax

Practice location:
  • Phone: 714-943-5015
  • Fax:
Mailing address:
  • Phone: 714-943-5015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberA114538
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA114538
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: