Provider Demographics
NPI:1053494831
Name:MCHENRY, DAVID GLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:GLEN
Last Name:MCHENRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0001
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:309 JACKSON ST STE 320
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7407
Practice Address - Country:US
Practice Address - Phone:318-966-8820
Practice Address - Fax:318-966-8827
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11473204D00000X, 2084N0400X
LA114732084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS18132Medicaid
MS18132Medicaid
MS347361YJ9XMedicare PIN
MS130000061Medicare ID - Type Unspecified