Provider Demographics
NPI:1003215047
Name:HENRY, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:HENRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 775985
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5985
Mailing Address - Country:US
Mailing Address - Phone:317-770-6900
Mailing Address - Fax:317-770-6911
Practice Address - Street 1:509 N PERU ST
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IN
Practice Address - Zip Code:46034-9499
Practice Address - Country:US
Practice Address - Phone:317-984-9311
Practice Address - Fax:317-984-9302
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001704A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN241888770Medicaid
IN241888770Medicaid