MEDICARE: W D HENCEROTH DO INC

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	207Q00000X	Family Medicine Physician	402712	OH

General Provider Information

NPI Number	:	1295700730
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	W D HENCEROTH DO INC

Provider Business Mailing Address
First Line	:	3774 BROADWAY
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-2235
Country	:	US
Telephone Number	:	614-875-6349
Fax Number	:	614-875-3633

Provider Business Practice Location Address
First Line	:	3774 BROADWAY
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-2235
Country	:	US
Telephone Number	:	614-875-6349
Fax Number	:	614-875-3633

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NANCY A HENCEROTH GATTO
Credential	:	D.O
Telephone Number	:	614-875-6349

Provider Enumeration Date	:	02/20/2006
Last Update Date	:	08/22/2020

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