Provider Demographics
NPI:1083675284
Name:HENRIKSEN, JOHN ERIC (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ERIC
Last Name:HENRIKSEN
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:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71754-0629
Mailing Address - Country:US
Mailing Address - Phone:870-235-3551
Mailing Address - Fax:870-235-3557
Practice Address - Street 1:101 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753
Practice Address - Country:US
Practice Address - Phone:870-235-3000
Practice Address - Fax:870-235-3557
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-29
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2924207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARE2924OtherAR MEDICAL BOARD
H42179Medicare UPIN