Provider Demographics
NPI:1093865115
Name:HENRY, CAMILLE (MD)
Entity Type:Individual
Prefix:
First Name:CAMILLE
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 1:1 FEDERAL ST # 200
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1088
Mailing Address - Country:US
Mailing Address - Phone:856-356-4924
Mailing Address - Fax:
Practice Address - Street 1:1865 HARRISON AVE STE 1300
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08105
Practice Address - Country:US
Practice Address - Phone:856-963-0126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09596200207R00000X
MA244133208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110087556AMedicaid
MA001669601Medicare PIN