Healthcare Provider Details

I. General information

NPI: 1588733497
Provider Name (Legal Business Name): EDWARD HENEGAR DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 HIGHWAY 160
GAINESVILLE MO
65655
US

IV. Provider business mailing address

1100 N KENTUCKY AVE
WEST PLAINS MO
65775-2029
US

V. Phone/Fax

Practice location:
  • Phone: 417-679-4613
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35006
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: