Healthcare Provider Details

I. General information

NPI: 1316358971
Provider Name (Legal Business Name): MARTHA HENAO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2014
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N 13TH AVE
UPLAND CA
91786-4904
US

IV. Provider business mailing address

555 N 13TH AVE
UPLAND CA
91786-4904
US

V. Phone/Fax

Practice location:
  • Phone: 909-277-2420
  • Fax: 909-206-1097
Mailing address:
  • Phone: 909-277-2420
  • Fax: 909-206-1097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA139610
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberA139610
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: