Provider Demographics
NPI:1366459273
Name:HENERY, RANDALL S (DO)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:S
Last Name:HENERY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 DIVISION AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-5429
Mailing Address - Country:US
Mailing Address - Phone:541-688-3000
Mailing Address - Fax:541-688-5368
Practice Address - Street 1:217 DIVISION AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-5429
Practice Address - Country:US
Practice Address - Phone:541-688-3000
Practice Address - Fax:541-688-5368
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD017983207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR052014Medicaid
E74968Medicare UPIN