Provider Demographics
NPI:1063456309
Name:HENRIKSON, KARL ERIC (MD)
Entity Type:Individual
Prefix:
First Name:KARL
Middle Name:ERIC
Last Name:HENRIKSON
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 1:85 FERDINAND ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-1154
Mailing Address - Country:US
Mailing Address - Phone:781-979-3120
Mailing Address - Fax:781-979-3994
Practice Address - Street 1:585 LEBANON ST
Practice Address - Street 2:RADIOLOGY DEPARTMENT
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3225
Practice Address - Country:US
Practice Address - Phone:781-979-3120
Practice Address - Fax:781-979-3994
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0458032085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3008231Medicaid
A58246Medicare UPIN
MAJ05181Medicare ID - Type Unspecified