Provider Demographics
NPI:1063499283
Name:HENRY, TAMIKA (MD)
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:
Last Name:HENRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 ARDEN AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-4059
Mailing Address - Country:US
Mailing Address - Phone:818-967-0789
Mailing Address - Fax:
Practice Address - Street 1:331 ARDEN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-4059
Practice Address - Country:US
Practice Address - Phone:818-967-0789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73743208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH63754Medicare UPIN
CAWA73743CMedicare ID - Type Unspecified