Basic Information
| Provider Information | |||||||||
| NPI: | 1033135868 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRETTA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1987 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462061987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776852164 | ||||||||
| FaxNumber: | 3177055060 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 ASHELAND AVE | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288014016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282139090 | ||||||||
| FaxNumber: | 8282139091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 9901198 | NC | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208600000X | 9901198 | NC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 8912394 | 05 | NC | MEDICAID | 12394 | 01 | NC | BCBSNC | OTHER |