Provider Demographics
NPI:1164511168
Name:HENKEL, BRODY LARS (MD)
Entity Type:Individual
Prefix:
First Name:BRODY
Middle Name:LARS
Last Name:HENKEL
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 1:2816 W VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6330
Mailing Address - Country:US
Mailing Address - Phone:813-876-6321
Mailing Address - Fax:813-870-0350
Practice Address - Street 1:2816 W VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6330
Practice Address - Country:US
Practice Address - Phone:813-876-6321
Practice Address - Fax:813-870-0350
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC289642084N0400X
FLME1093042084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology