Basic Information
| Provider Information | |||||||||
| NPI: | 1033294152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSHOT | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | JENNINGS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ACKERMAN RD STE 2120 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432021559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142938116 | ||||||||
| FaxNumber: | 6142933555 | ||||||||
| Practice Location | |||||||||
| Address1: | 915 OLENTANGY RIVER RD | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432123153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142938116 | ||||||||
| FaxNumber: | 6142933555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 01/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 35093284 | OH | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0120X | 35093284 | OH | Y |
ID Information
| ID | Type | State | Issuer | Description | 2992605 | 05 | OH | MEDICAID |