Healthcare Provider Details

I. General information

NPI: 1003907411
Provider Name (Legal Business Name): HENRIETTA M. MAHONEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NEMOURS PEDIATRICS PHILADELPHIA PIKE 222 PHILADELPHIA PIKE
WILMINGTON DE
19809-3166
US

IV. Provider business mailing address

PO BOX 191 PROVIDER ENROLLMENT DEPT
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 302-761-4660
  • Fax: 302-761-4666
Mailing address:
  • Phone: 302-651-6212
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC10007873
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberC10007873
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: