Provider Demographics
NPI:1134119258
Name:HENLEY, ERIC (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:HENLEY
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 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003
Mailing Address - Country:US
Mailing Address - Phone:928-213-6100
Mailing Address - Fax:928-774-6687
Practice Address - Street 1:2920 N 4TH ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1816
Practice Address - Country:US
Practice Address - Phone:928-213-6100
Practice Address - Fax:928-774-4808
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ41576207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ415734Medicaid
AZ415734Medicaid